Tomotherapy Based Image Guided Imrt

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  • 1. IMPLEMENTATION OF A TOMOTHERAPY BASED IMAGE- GUIDED IMRT PROGRAM THROUGH A FULL SCOPE OF RADIATION THERAPY PRACTICE MODEL The Ottawa Hospital Regional Cancer Centre Ottawa, Ontario April 2008
  • 2. The Ottawa Hospital Cancer Centre • Treats approximately 4000 patients annually • 9 conventional linacs (6 Siemens, 3 Elekta Synergy) • 2 TomoTherapy Hi-ART
  • 3. Implementation of 1st Unit •Installation = 8 days •Acceptance and commissioning = 2 weeks •Therapist training = 2 weeks •1 week without patients •1 week with patients •1st patient = 12 September 2005 •Initially 5-6 patients/day •2nd Tomo Unit installed Oct/07 •Currently treat 18-20 patients in 8hr day •25 min bookings
  • 4. Patients Treated from Sept 05- Current Site Number of Patients H&N 128 PELVIS 83 SPINE 22 CNS 24 LUNG 23 ABDOMEN 7 BREAST 23 TOTAL 311
  • 5. Treatment and Planning • Started with three therapist planning and delivering treatments – Selected therapists had no previous treatment planning experience – Training was excellent – Visited three other Tomo sites to gain knowledge and experience – Planning is an on-going learning experience
  • 6. Average Planning Time (min) Task 1st 3m After 9m 70 40** Rad Onc. Targets 86 23 Work @ Planning Station 22 6 ROIs 82 73 Beamlets 180 120 Optimization 33 6 Time with Onc 62 60 Physics QA Total 535 328 Currently, average time = 5.5hrs **Some targeting takes longer than 40 mins
  • 7. Planning • Therapists like treatment/planning model because: – More knowledgeable when registering MVCT – Therapists are able to adjust treatment plans to reduce/limit some observed side effects – No ‘hand off’ or transfer of information – Able to contribute to prospective protocols • We now have 7 therapists for 2 units on ‘Team Tomo’
  • 8. Cord Not Aligned – Need for PRV Inf. End of cord not perfectly Sup. aligned. End ok. Yellow = PRV cord – good thing PRV= Planning at Risk Volume (ICRU recommendation)
  • 9. Tomo Group Meetings • Radiation Oncologists, Therapists and Physics meet weekly to determine: – Who is eligible for treatment (protocols) – Who can benefit most from IMRT treatment (nonprotocol) • Potential CTVs are reviewed to determine: – Need for bolus and its placement – Immobilization device requirements • Review treatment plans of patients on treatment
  • 10. Therapist Perspective • Therapists feel they are; – Using full-scope-of-practice – Involved at all levels of decision making • Patient suitability • Targeting • Planning • Treatment • Education • Research
  • 11. Additional Responsibilities • Protocol development • Image-guided treatment delivery • Development of policy and procedures • Research – Testing of new software – Adaptive planning – Publications
  • 12. RTOG 0521 66/60/56 in 33 Added sparing structures used to reduce toxicities
  • 13. Unknown Primary 66/60/56 in 33 Targets are homogeneous
  • 14. OTT 06-04 In-house Breast + Nodes(IMC) Protocol
  • 15. OTT 06-04 In-house Breast + Nodes(IMC) Protocol V20= 6.8% V5 = 36%
  • 16. T2N1MO Squamous cell Anus Three PTV’s 60/55/48 in 30 (+chemo) Rad Onc initially wanted to treat patient in three phases. Tomo team was able to created plan using alternate fractionation.
  • 17. Whole Brain 3000/10 + Simultaneous Boost to 3 iso 4500/10 in 1plan (25 min) **London Protocol
  • 18. CNS – Avoidance Structure in Mid Brain Therapist created this distribution. Pt is treated supine and has reduced toxicities
  • 19. StatRT = Scan/Plan/Treat = 40 min Scan • Place patient on the couch • Scan selected region • Acquire MVCT image set Plan • Perform 3D contouring at the Operator Station • Set prescription • Optimize the treatment fraction • Evaluate using isodose distribution and dose volume histograms (DVHs) Treat • Helical IMRT delivery • Conformal 3D dose distributions • Simple to complex cases
  • 20. Clinical Pilot • 25 palliative patients • Fractionated and single treatments – Spine – Abdo – Lung – Pelvis
  • 21. StatRT - Two Targets Rt Hip and Peri-Rectal mass
  • 22. StatRT - Two Targets Rt Hip and Peri-Rectal mass
  • 23. Multiple Targets
  • 24. Simple Targets
  • 25. Mycosis Fungoides (20/5 to Blue and 15/5 to Red) Previous TBE 3500/20 (using 6 or 9 MeV electrons) in 2003
  • 26. Mycosis Fungoides (20/5 to Blue and 15/5 to Red)
  • 27. Before and After before before after
  • 28. Our Team Medical Physics Radiation Oncology – Jason Belec – Rob MacRae – Brenda Clark – Laval Grimard – Lee Gerig – Shawn Malone – Miller MacPherson – Libni Eapen – Gosia Niedbala – And a dozen more – Balaz Nyiri – Janos Szanto Electronics Radiation Therapy – Gaetan Belanger – Lynn Montgomery – Georges Gohier – Kathy Carty – Greg Fox – Najib Nassar – Jamie Bahm – Bev Macallum Questions: – Karen Vanderwerff lmontgomery@ottawahospital.on.ca – Kirsten Keeler – Andre Patry Kvanderwerff@ottawahospital.on.ca – Sandra Hamilton