2009 Emea 4D Tomotherapy

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2009 Emea 4D Tomotherapy

  1. 1. EMEA 2009 Tomotherapy User Meeting 4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE EFFECTS OF THE TARGET MOTION G.Guidi 1 , M.Amadori 2 , E.Cenacchi 1 , L.Morini 1 , C.Danielli 1 , F.Bertoni 2 1 Medical Physics Dpt. 2 U.O. Radiation Oncology Azienda Ospedaliero - Universitaria di Modena - Policlinico “… under the “Ghirlandina” Tower…. … ..new opportunities and ideas are growing … … and many people are working on it”
  2. 2. CLINICAL RESEARCH – INTERCOMPARISON – TRIALS (TO ACQUIRE TOMOTHERAPY) <ul><li>NSCLC : Efficacy and tolerances of exclusive and post-surgery radiation therapy treatments with/without chemo association, using CT-PET and Dynamic IMRT. Patients survivor and/or time progression analysis. Procedures and cost-benefit evaluation. (Prof. L.Fabbri, Prof. U.Morandi, Prof. B.Bagni, Dr. F.Bertoni, Dr. C.Danielli) </li></ul><ul><li>H&N : Radical treatments with chemo association using Dynamic IMRT, IGRT and Adaptive Radiation Therapy. Treatment conformity index, patients tolerance, efficacy and cost-benefit evaluation using Tomotherapy (Prof. P.F.Conte, Prof. A.Falchi, Dr. F.Bertoni, Dr. C.Danielli) </li></ul><ul><li>TBI (National Health Research - PIO V): Clinical and dosimetric evaluation of Total Body Irradiation using Tomotherapy. Transplant procedure, adequacy and safety evaluations of the treatments using Tomotherapy. Problem solving, efficacy and efficiency. (Prof. G.Torelli, Dr. F.Bertoni, Dr. C.Danielli) </li></ul><ul><li>PAEDIATRIC : Clinical evaluation of paediatric treatments. Paediatric patients management and performance assessment for high conformal and complex treatment using Tomotherapy. Clinical advantages and disadvantages. (Prof. P.Paulucci, Dr. F.Bertoni, Dr. C.Danielli) </li></ul><ul><li>BRAIN : Clinical study for upper-tentorial cerebral treatment using Tomotherapy. Clinical advantages and disadvantages, cost-benefit impact and patient management (Prof. G.Pinna, Dr. L.Mavilla, Prof. B.Bagni, Dr. F.Bertoni, Dr. C.Danielli) </li></ul><ul><li>TECHNOLOGY ASSESSMENT : Technical, dosimetric and cost-benefit evaluation of a Tomotherapy Unit. Routine applicability in a Public hospital for high conformal, IGRT and Adaptive Radiation Therapy treatment. Develop and optimization of treatment delivery, commissioning and Quality Assurance procedures. Time estimation and requirement to implement protocols and techniques (Dr. F.Bertoni, Dr. C.Danielli, Dr. Eng. M.Lugli) </li></ul><ul><li>TRIALS AND INTERCOMPARISON </li></ul><ul><li>IRMA – Partial Breast Irradiation ( www.irmatrial.it ) </li></ul><ul><li>CHPLT2008 A- H&N Multicentric Intercomparison </li></ul><ul><li>MESOTHELIOMA (Intercomparison IMRT vs. Tomotherapy vs. Protons) </li></ul><ul><li>NSCLC – Intercomparison CNAO (Photons - Protons) </li></ul>
  3. 3. LET’S START FROM WHO HAS MORE EXPERIENCES THAN US
  4. 4. RADIATION ONCOLOGY WORKFLOW ANALYSIS Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population
  5. 5. 4D WORKFLOW ANALYSIS (4D TOOLS AND ISSUES) Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Gamma Index? 4D Dose Point? 4D Edge Profile? Accuracy? 4D Inverse Planning (Same results?) Which Plan or Phases? Which Phases to be consider? Trigger Tomotherapy is possible? 4D-MVCT? Tracking the delivery 4D Adaptive RT Reconstruction
  6. 6. 4D WORKFLOW ANALYSIS - IMAGING & CONTOURING Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations
  7. 7. 4DCT AND GATING/TRACKING DEVICES (TOSHIBA + VISION RT) Advantages: 4DCT Exams (10 CT Dataset – 0-100% Breathing Phases): Very Fast (few minutes) – Retrospective Mode Range Slice thickness for our RT: 0.5 - 3 mm (5mm used for Cranio Spinal Irradiation and TBI) VisionRT detect capability: 1-2mm of the couch movement (VisionRT can appreciate the ramp up of the couch during the CT scan) Issues: 4DCT Images Reconstruction (>1000 Images – 10 CT Datasets – 5/6 Hours of reconstruction) Thickness 0.5mm could be useful for Radiosurgery but dose issues and the Tomotherapy image resample (256x256 ) could create problems Troubles and investigation: Mismatch image reconstruction due to the couch ramp-up and the breathing signal (Sinogramma Editing in develop by Toshiba) Limited Trigger Time of 10 cycles/min not applicable (No idea why ????) Work on Phases 20-60% (5 CT Datasets) - 2-3mm Slice Thickness Contour all CTVs and OARs using TPS (Not Applicable). During routine is contouring Min exhale and Max inhale phases, but is no equal to contour the CTVs for each phases Trick Necessary
  8. 8. PINNACLE 4D RESEARCH CONSOLE Contouring Objectives: Define contours that include all the organ and tumor movements due to the cycles Issues: Contouring each phases is very long time consuming using standard TPS Advantages using Pinnacle 4D Console: Contouring the CTVs of the Multiple Phases (20-60%) and propagate ROI and OARs to all others 4DCT exams Use the Model Based Segmentation to speed up the contouring time Create an average MIP exams to accelerate the evaluation of the volumes Create an ITV as integration of all the CTVs contoured in each phases Beta Test Console: Courtesy of TA Tecnologie Avanzate CT Movement Artifact (Lung or Liver)
  9. 9. FOCAL 4D RESEARCH CONSOLE Contouring Objectives: Define contours that include all the organ and tumor movements due to the cycles Issues: Contouring each phases is very long time consuming using standard TPS Advantages using Focal 4D Console: Contouring the CTVs of the Multiple Phases (20-60%) using MIP Cine Contouring on axial, coronal and sagittal view Propagate ROI and OARs to all others 4DCT exams Create an ITV as integration of all the CTVs contoured in each phases Beta Test Console: Courtesy of TEMA Sinergie
  10. 10. 4D WORKFLOW ANALYSIS – PLANNING & DOSE COMPUTATION Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D Inverse Planning (Same results?)
  11. 11. 4D PLANNING & 4D DOSE COMPUTATION Simulation of a 4D Lung treatment Create beamlets and plans for each phases and CTVs contoured (Total of 5 plans + 1 Plan for the ITV) Comparison of the multiple plans calculated on the CTVs vs. plan on the ITV Questions? If I don’t use any margin to the CTV? Suspected under dosage of the ITV without 4D evaluation of the CTV or to the Target in general <ul><li>Question? </li></ul><ul><li>Are there any clinical issues due to the target motion? </li></ul><ul><li>Any implication on boost or BTV contoured without target motion evaluation? </li></ul><ul><li>Any missing during a stereotactic treatment? </li></ul><ul><li>Can I reduce CTV or ITV margins with Tomotherapy? </li></ul>ITV CTV
  12. 12. 4D MULTIPLE PLAN EVALUATION CTV20 (phase 20%) CTV30 (phase 30%) CTV40 (phase 40%) CTV50 (phase 50%) CTV60 (phase 60%) ITV (phase 20%) ITV (phase 30%) ITV (phase 40%) ITV (phase 50%) ITV (phase 60%) Upper Lobe Lesion & Small Volume  40% of Dose differences between CTV and ITV ... Question? Do I need a margin? Are enough accurate the voxel dimension for a 4DRT? (256x256)? <ul><li>Export Tomo Doses to CERR and process it </li></ul><ul><li>Long time consuming, but it is possible to evaluate and analyze multiple plan at the same time </li></ul>Phase Dose Matrix Structure Phases Dose Maps CERR: Courtesy of Prof. Joseph Deasy – Prof. Issam El Naqa
  13. 13. 4D MARGIN EVALUATION (4 PLANS : TARGET=PTV) PTV=CTV PTV=ITV PTV=CTV+0.5cm PTV=CTV+ 1cm Suspected CTV Voxel Issue correlated to the dose grid or to the image resample : Under investigation CTV ITV CTV ITV CTV ITV CTV ITV
  14. 14. 4D DOSE RECONSTRUCTION 4D DOSE RECONSTRUCTION OF THE RESPIRATORY PHASES (Possible!!! But I will be crazy, if it will be a clinical routine (3 days of work)) Dose Matrix (Phase 20%) + Dose Matrix (Phase 30%) + Dose Matrix (Phase 40%) + Dose Matrix (Phase 50%) + Dose Matrix (Phase 60%) + ------------------------------------ 4D Dose Reconstruction The breathing sinogramma will define the time (BIN) for each Dose Matrix
  15. 15. 4D QA Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Inverse Planning (Same results?)
  16. 16. LET’S GO TO THE QA AND ANALYZE THE REAL DOSES DELIVERED (DQA) THEORY AND PRACTICE COULD BE DIFFERENT Preliminary dosimetric issue of the Patient DQA using QUASAR Phantom Respiratory phases 15 cycles/min Active Target Simulation : 0.5 cm movement (Cranio – Caudal) during Tomo delivery The dynamic phantom has a dedicated Gaf-Chromic and Ion chamber insert Dosimetric differences appraisal using Gaf-Chromic Film X Coordinate: Edge of the CTV near the Gantry Y Coordinate: CTV Coronal Profile Dose measured and calculated are different and shifted, especially near the tumor edges Gamma Index 3%@3mm can help me ? Calculated : 2.25 Gy Measured : 1.75 Gy
  17. 17. 4D GAF CHROMIC ANALYSIS (GAMMA INDEX 3% @ 3mm) Inside the target seems to be delivered an adequate dose... .. but the dose at the border of the target looks very different from the plan Calculated : 2 Gy Measured : 1.75 Gy <ul><li>Can I accept the DQA? </li></ul><ul><li>X - Y direction are not adequate </li></ul><ul><li>Z –Y direction analysis can be done using same method </li></ul><ul><li>X-Y-Z direction at the same time ....not at the moment with this phantom </li></ul>
  18. 18. QUESTION ? WHICH IS THE DOSE DELIVERED DURING A BOOST OF THE BTV AND THERE ARE NO MARGINS OR ITV EVALUATION? <ul><li>Which dose we deliver to the BTV (e.g. SIB or BTV Boost), without any extra margin.... </li></ul><ul><li>.....maybe some active cancer cells inside, could be underdosed </li></ul><ul><li>Currently we are using PET for target definition, but we should evaluate the 4D CT/PET information </li></ul><ul><li>BTV definition </li></ul><ul><li>ITV definition (IBTV : Internal Biological Target Volume) </li></ul><ul><li>Windows Thresholds </li></ul><ul><li>Type of tracer </li></ul><ul><li>...... </li></ul>4D CT/PET : Work in progress 4D CT/PET : Different case ITV CTV
  19. 19. LET’S GO BACK TO PHANTOM AND LET’S TRY TO SIMPLIFY THE PROBLEMS Preliminary results using a dynamic Phantom (Quasar) Respiratory phases 15 cycles /min The easiest sinogramma (periodic and constant - sinusoidal) Evaluate Cranial Caudal direction Analysis Target Movement: 1 cm EVALUATE THE RESULTS 4D Motion Artifact (Should be a circle) <ul><li>Equal Workflow but in a Phantom </li></ul><ul><li>Acquire a4DCT Exams of the phantom </li></ul><ul><li>Contour and define the inserts objects for each phases (Cube and Spheres) </li></ul><ul><li>Create multiple plan </li></ul><ul><li>Evaluate the dose delivered using Gaf and Ion Chamber </li></ul><ul><li>Analyze the easiest problem </li></ul>EASY ANALYSIS CONDITION Defined Direction Defined Structures Revolutions and Movements Rigid Phantom Defined Sinogramma
  20. 20. TRY TO SIMPLIFY THE PROBLEMS .... VERY SIMILAR RESULTS Preliminary results using a dynamic Phantom (Quasar) Respiratory phases 15 cycles /min Cranial Caudal direction Analysis (4D Phantom can’t permit to analyze the X,Y,Z coordinate at the same time) Target Movement: 1 cm Morphing of the structures (4D Issue and Investigation) Dosimetric impact of the structure morphing due to respiratory motion Dose Shift 1cm Cranial under dosage and caudal over-dosage should be considered Dosimetric results on Gaf-Chromic: shift of  1cm (Cranial Caudal direction) MODERATE DOSE DIFFERENCES BUT GAMMA INDEX AND DOSE ACCURACY NOT ACCEPTABLE FOR A PATIENT TREATMENT Gamma Index due to respiratory motion
  21. 21. 4D ADAPTIVE RADIATION THERAPY Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Gamma Index? 4D Dose Point? 4D Edge Profile? Accuracy? 4D Inverse Planning (Same results?) Which Plan or Phases? Which Phases to be consider? Trigger Tomotherapy is possible? 4D-MVCT? Tracking the delivery 4D Adaptive RT Reconstruction NO ANSWER AT THE MOMENT... ... BUT FEW IDEAS TO USE MVCT
  22. 22. 4DCT AND PATHOLOGY EXAMS (JUST TO COMPLICATE THE PROBLEMS) (LUNG INVESTIGATION – COLLBORATION WITH CNAO) <ul><li>Compare the tumor shrinking (from formalin) </li></ul><ul><li>Analyze 4DCT studies and define rotational – translation matrix </li></ul><ul><li>Analyze 4DCT studies and define the volume evolution during breathing acts </li></ul><ul><li>Merge CT and Anatomy-Pathology exam </li></ul><ul><li>Try to confirm PET and MRI (not for lung) contouring </li></ul><ul><li>Working with CNAO Groups to compare Treatments with Protons and Carbon Ions and Gating Radiation Therapy </li></ul><ul><li>… Dynamic IMRT Treatment of the lesions using robotic couch or Tomotherapy.... </li></ul><ul><li>.... if the 4D or the technology will be available.... </li></ul>Group Coordinator : Prof. Lorenzo Magno CNAO Work-Group for Lung Carcinoma (NOC) Radiotherapy : Filippo Bertoni : [email_address] Mario Bignardi : [email_address] Luigi Franco Cazzaniga : [email_address] Giovanni Frezza : [email_address] Fabrizio Salvi. [email_address] Marta Scorsetti : [email_address] ... Medical Physics : Gabriele Guidi: [email_address] t Marcella Palombarini: [email_address] Anatomo-Pathology i: Giulio Rossi: [email_address] Radiology : Maria Grazia Amorico: A .Ospedaliero-Universitaria di Modena Ennio Gallo : [email_address] Pietro Torricelli: [email_address] Nuclear Medicine : Bruno Bagni: Università degli Studi di Modena e Reggio Emilia Pneumology : Mario Bavieri: U.O. di Pneumologia , A .Ospedaliero-Universitaria di Modena Emmanuela Meschiari: U.O. di Pneumologia, A .Ospedaliero-Universitaria di Modena Torax Surgery : Corrado Lavini [email_address] Uliano Morandi: Università degli Studi di Modena e Reggio Emilia Oncology : Fausto Bavieri: U.O. di Oncologia, A .Ospedaliero-Universitaria di Modena Psychology Annamaria Bonardi [email_address] Biometric : Roberto D’Amico: Ufficio Trial Dip. di Onc. ed Ematol., A. Ospedaliero-Universitaria di Modena Work in Progress : Gabriele Guidi – Giulio Rossi Multicentric Intercomparison Photons vs. Protons Anatomy-Pathology exam before formalin Anatomy-Pathology exam after formalin
  23. 23. Conclusions Special Thanks to Elisa & Luciano <ul><li>4D could be applicable by any center with a 4DCT and a tracking device </li></ul><ul><li>Long time consuming (imaging, contouring, plan, dose and QA) especially without 4D Tools </li></ul><ul><li>Many open issues, about dosimetry (Shift and Under-dosage) </li></ul><ul><li>Evident missing at the border of the target (do we need specific target margin?) </li></ul><ul><li>Target motions has a big influences on the real doses delivered (Anatomical missing and potential failure of the RT) </li></ul><ul><li>4D dose reconstruction could help to analyze the results </li></ul><ul><li>ITV can guaranties a partial margin reduction </li></ul><ul><li>4D with Tomotherapy: necessary to use ITV or adequate margin to the target and analyze carefully your clinical objective, before to treat patient </li></ul><ul><li>4D work with time..... </li></ul><ul><li>....we need time to investigate the problems... </li></ul><ul><li>...but patience and any help could be important!! </li></ul>4D Physicist Doctors Will I see a 4D Tomotherapy Treatment? EMEA 2009 Tomotherapy User Meeting 4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE EFFECTS OF THE TARGET MOTION G.Guidi 1 , M.Amadori 2 , E.Cenacchi 1 , L.Morini 1 , C.Danielli 1 , F.Bertoni 2

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