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 HDR planning principles for prostate brachytherapy
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HDR planning principles for prostate brachytherapy

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  • 1. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy HDR Planning Principles Frank-André Siebert
  • 2. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy HDR Planning Principles  Equipment  Imaging  Dose calculation and planning  Workflow  Specials
  • 3. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Basics HDR Afterloading device Source cable moveable Implant needle
  • 4. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Basics Iridium-192 T1/2 = 73.81 days Effective energy = 0.3719 MeV Length: 3.5 - 5 mm Diameter: about 1 mm Source HDR: High Dose Rate > 12 Gy/h
  • 5. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Basics • Parallel implant geometry • Dwell positions (1), discrete • Dwell times (2) Step size, e.g. 5 mm Dwell positions with dwell times ⇒ Two variables for treatment planning ⇒ IMBT Intensity Modulated Brachytherapy
  • 6. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy 5s5s 5s 5s 5s 5s 5s 5s 5s 4s 4s 2.7s 5s Dwell times and dwell positions
  • 7. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Basics Rivard et al. Update of AAPM Task Group No. 43 Report: A revised AAPM protocol for brachytherapy dose calculations. Med Phys 2004 TG-43 Formalismus Sk: Air-Kerma-Strength Λ: Dose-Rate constant GL: Geometry function gL: Radial Dose function F: Anisotropy function
  • 8. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy The evolution of brachytherapy treatment planning Rivard et al. Med Phys 36(6), 2009 Recommendations of the AAPM/ESTRO/ABS TG-186 (just submitted)
  • 9. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy How / when do we perform the treatment planning ? Preplanning Intra-operative planning some days before implantation in the operation theatre CT-based postimplant procedure • Different timing • Different images • Same treatment planning techniques
  • 10. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Basics Treatment planning techniques: 1. Forward planning 2. Geometrical optimization 3. Inverse planning (volume optimization) 4. Combinations 1.-3. How can I persuade the planning computer to calculate a proper plan?
  • 11. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Forward planning • User biased • Needs experience • Fast
  • 12. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Forward planning, shaping tools Good tools, but check the dwell times!
  • 13. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Geometrical optimization Ti Pref • Relative dwell times are inversely proportional to the distance to other dwell positions • Can be normalized to reference point • Very fast • Not based on anatomy
  • 14. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Geometrical optimization • Easy to use • Not anatomy based
  • 15. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Inverse Planning Dose constraints for individual organs needed
  • 16. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Inverse planning Convert dose distribution Di to penalty value wi (dij: dose rate matrix)   8.5 Gy Energy E.g. Dprostate ≥ 8.5Gy  (Summation over all dose points) (Summation over clinical criteria)
  • 17. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Inverse planning E Iterations Dwell times tj change until global minimum EMin is reached. EMin
  • 18. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Inverse Planning  No one-click solution  Constraints must be adapted  User-independant solution  Can save time  Check the results Optimal result Inverse planning ?
  • 19. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy B. Lachange et al. IJROBP 2002 (54) 86-100 IPSA better than geometrical optimization
  • 20. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Comparison of Conventional and Inverse Planning Campus Kiel, Clinic of Radiotherapy Conventional Planning (CP) Inverse Planning (IP) p- Value D90 CTV1 [Gy] 5.62 5.63 0.67 D90 CTV2 [Gy] 11.03 10.89 0.38 V200 CTV1 [%] 29.83 29.87 0.80 V200 CTV2 [%] 5.76 8.14 <0.01 COIN CTV1 0.26 0.30 0.17 COIN CTV2 0.54 0.52 0.86 D2cc Rectum [Gy] 6.04 6.12 0.09 D0.1cc Urethra [Gy] 9.57 9.52 0.34 Dosimetric and quantitative parameters used for analysis. The means of 38 plans considered are shown. Statistically significant is only the difference in V200 for CTV2. The inverse planning still tends to so-called hot spots, although dwell smooth function had been set to 100%. Wolf et al. Radiother Oncol 103: S134 (Supplement 2).
  • 21. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Med Phys 2011 Milickovic et al. The observed average displacement of needles (1 mm) and of prostate (0.57 mm) is quite small as compared with the average displacement noted in several other reports
  • 22. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Med Phys 2011 Milickovic et al.
  • 23. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Kiel method for HDR prostate (boost) : Setup  Preparation of patient: enema the evening before or Glycilax® in the morning before treatment  Patient positioning in lithotomy position (spinal / global anesthesia)  Transrectal ultrasound (TRUS)  Stepper unit  Parallel needle guidance by template
  • 24. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Kiel concept of HDR-Brachytherapy for prostate cancer  Prostate volume < 60 ml  Staging: T1-T3  Distance rectum to prostate > 5 mm  BT: 2 x 15 Gy plus EBRT: 50 Gy (pelvis), 40 Gy (prostate) BT 15 Gy FinishStart BT 15 Gy EBRT 20 Gy 2 weeks EBRT 20 Gy 2 weeks EBRT of pelvis 10 Gy 1 week Prostate block in 0° and 180°
  • 25. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy
  • 26. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Kiel concept of HDR-Brachytherapy for prostate cancer  Hardware:  B&K TRUS Profocus 2202 scanner, transducer type 8848  AccuSeed DSTM floor mounted stepper  3.33 mm template  Trocar point steel needles  Philips C-arm  GammaMedPlusTM afterloader
  • 27. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy AccuSeed DS stepper with BK 8656 transducer
  • 28. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Biplane TRUS Transversal image acquisition (2D) ∆z=2.5mm Longitudinal image acquisition (2D) ∆Θ 3D dataset
  • 29. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy at z=1 cm Transversal image acquisition (2D) Longitudinal image acquisition (2D) and reconstruction
  • 30. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Teamwork is essential Urologist Technician, nurse, … Radiotherapist Physicist Anesthetist
  • 31. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy  Kiel: U-shape form of needles  Needle positions are set by experience dist.: 5-10 mm  Use information of biopsy report Needle implantation Geometry is essential
  • 32. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Ultrasound Acquisition Definition of reference plane VitesseTM 2.0
  • 33. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Needle detection in transversal plane
  • 34. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Needle tip detection in longitudinal plane Stepper with encoder is sending dΘ and dz to planning system dz dΘ
  • 35. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Contouring
  • 36. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Needle curvature
  • 37. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Dose calculation:  Source stepping distance: 5 mm  Maximum dwell times: 12 s  Dwell time resolution 1/10 s  Dose prescription  CTV1: 15 Gy (Periphery)  CTV2: 8-9 Gy (Prostate gland)  Urethra dose: < 10 Gy  Rectum dose: < 8 Gy
  • 38. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Dose calculation in BrachyVision 1. Step: 4s dwell time at each position (336s) 1. Step in dose calculation: Set all dwell times constant to 4 s (336 s)
  • 39. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Dose calculation in BrachyVision 2. Step: manual optimization of dwell times (331s) 2. Step in dose calculation: Manual optimization (313 s)
  • 40. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Time schematic for operation room (OR) Time 0‘ 5‘ 15‘ 30‘ 40‘ 50‘51‘ 60‘ 65‘ 70‘ 75‘ 90‘
  • 41. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Transfer to afterloader console
  • 42. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Practical hints Correct connection of Transfer tubes
  • 43. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Check channel numbers !
  • 44. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy „Crossed“ needles
  • 45. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Practical hints  Good US image quality necessary  Patient must be well prepared  Avoid patient movements  US balloon without air bubbles  Enhanced urethra visibility by foamy gel in catheter  Insert needles with speed and force  Tilt needle if possible and necessary
  • 46. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Practical hints Ultrasound set-up Very important Check proper fixation probe on stepper Few pressure on prostate
  • 47. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Practical hints  Needle tip not clearly visible  Compare needle ends to known needle positions ?
  • 48. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Deflating the balloon from 30ml to 0ml
  • 49. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy
  • 50. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Needle tip reconstruction Siebert et al. Med Phys 2009 Frequency: 9 MHz 15 dB -15 dB
  • 51. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Implant needle tip Tip End of hollow part First dwell position
  • 52. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Intra-operative HDR planning Disadvantages  Working under pressure of time.  Whole team must be present. Advantages:  We know with high accuracy where the dose will be delivered.  Situation of treatment plan is close to reality.  Whole team is present.
  • 53. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Campus Kiel, Clinic of Radiotherapy Checklist: HDR program (new / improvement)  Literature research, courses (e.g. ESTRO)  Patient selection  Equipment: hardware, software, imaging  Radiation protection  Configure TPS  Prescription dose, dose constraints  Training  Dummy run (phantom)  Establish QA program  …
  • 54. UNIVERSITÄTSKLINIKUM Schleswig-Holstein UNIVERSITÄTSKLINIKUM Schleswig-Holstein Thank you for your attention ! Campus Kiel, Clinic of Radiotherapy