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  1. 1. WellSpring Oncology Tomotherapy
  2. 2. WellSpring Oncology
  3. 3. Improving radiation technology from radium and cobalt to image guided IMRT ( Tomotherapy ) and stereotactic radiosurgery ( Cyberknife )
  4. 4. CT scan and sometimes a PET scan are obtained at the time of simulation CT images (or fusion with PET scans) are then imported into the treatment planning computer to develop sophisticated targeting plans
  5. 5. Advantages of using image guided IMRT with the Tomotherapy technology <ul><li>Because the beam angles are not limited it is possible to generate extremely complex and sophisticated computer plans </li></ul><ul><li>Because a CT is taken just prior to each treatment, the set up can be very precise and accurate, and if the tumor is shrinking, the fields can be adjusted during the course of treatment (called Adaptive Radiotherapy) </li></ul><ul><li>Specific sites </li></ul><ul><ul><li>Bone Mets </li></ul></ul><ul><ul><li>Brain tumors </li></ul></ul><ul><ul><li>Breast Cancer </li></ul></ul><ul><ul><li>Colon and Rectal Cancer </li></ul></ul><ul><ul><li>Esophagus </li></ul></ul><ul><ul><li>Gynecologic Cancers </li></ul></ul><ul><ul><li>Head and Neck </li></ul></ul><ul><ul><li>Lung </li></ul></ul><ul><ul><li>Prostate </li></ul></ul>
  6. 6. Bone Metastases
  7. 7. Bone Metastases to the Spine Involved vertebrae on the left and normal on the right
  8. 8. Kidney cancer in the spinal vertebrae surrounding the cord, and appearance after radiation…is it possible to safely radiate further?
  9. 10. Spinal Cord Syndrome
  10. 11. Dose reconstruction for cord compressions retreatments using helical tomotherapy S.L. Mahan, C. Ramsey IJROBP Volume 60, Issue 1, Pages S640-S641 (September 2004) patients with cord compressions that had received previous radiation therapy were imaged and treated on a HI-ART helical tomotherapy system dose calculations for no image guidance, the mean increase in spinal cord dose was 86.4% making treatment delivery impossible without image-guidance. Dose calculations were also made considering image guidance. These doses represent what should have been delivered using daily MVCT imaging. The mean increase in spinal cord dose was 5.2% making fractionated treatment delivery to 30 Gy possible even with minimal immobilization.
  11. 12. Treating Multiple Sites at the Same Time is Possible with Tomotherapy
  12. 13. Brain Tumors
  13. 14. Whole brain irradiation
  14. 15. Whole brain radiation
  15. 16. The response or benefit from whole brain radiation takes several weeks to months
  16. 17. Memory – stem cell areas of the brain that should be avoided with radiation
  17. 18. May be possible to protect memory areas and still hit brain mets using Tomotherapy
  18. 19. Breast Cancer
  19. 20. Typical technique for external beam
  20. 21. Radiation beam skims over the surface of the chest wall, ribs and luring
  21. 22. Internal doses of radiation surface doses of radiation Computer generated breast radiation Tumor site in breast lung lung Spinal cord heart breast
  22. 23. Computer generated anatomy images that will identify all the important structures to be sure the radiation covers the area of breast cancer and limits the dose to other areas
  23. 24. Viewed from the side, the radiation stops before hitting the lung
  24. 25. Typical CT Scan after Lumpectomy for Radiation Planning, sometimes fluid collects at the surgery site (seroma) and sometimes the surgeon places clips to mark the area clip clip seroma Boost target heart lung lung
  25. 26. Radiation boost targets the high risk area, identified by the lumpectomy incision, or the seroma or surgical clips if placed
  26. 27. Helical Tomotherapy Planning for Left-Sided Breast Cancer Patients With Positive Lymph Nodes: Comparison to Conventional Multiport Breast Technique Goddu. IJROBP 2009;73:1243 The tomotherapy plans provided better dose conformity and homogeneity than did the three-dimensional plans for treatment of left-sided breast tumors with regional lymph node involvement, while allowing greater sparing of the heart and left lung
  27. 28. Cancer of the colon and rectum
  28. 29. Side Effects of Pelvic Radiation Radiation fields Radiation may hit the small bowel causing some cramps, diarrhea and fatigue
  29. 30. Case Study: Recurrent Colon Cancer with Unresectable Mesenteric Mass
  30. 31. Recurrent Mass surrounded by loops of normal bowel , so technically difficult to treat with conventional radiation cancer bowel bowel
  31. 32. Using Tomotherapy we can better target the cancer and limit the dose to normal structures Radiation dose cloud Radiation dose cloud
  32. 33. Computer generated images of anal cancer
  33. 34. Tomotherapy for Anal Cancer
  34. 35. Tomotherapy for anal cancer, high dose to anus and groin nodes, while avoiding the bladder and femurs
  35. 36. Esophagus Cancer
  36. 38. PET Scan = Cancer in Lower Esophagus
  37. 39. PET Scan Images are used to construct radiation target in the treatment planning computer
  38. 40. PET Scan Images are used to construct radiation target in the treatment planning computer
  39. 42. Actual patient treatment images on the Tomotherapy machine
  40. 43. Small cancer in very elderly patient, the PET used to develop small highly targeted TOMO fields
  41. 44. Gyn Cancers
  42. 45. Uterine cancer can spread to lymph nodes
  43. 46. Radiation for advanced cervix cancer involving both pelvic and para-aortic nodes
  44. 47. Tomotherapy for Advanced Cervix Cancer
  45. 48. Head & Neck Cancer
  46. 49. CT-Pet Anatomy small cancer in the front of the tongue (oral tongue)
  47. 50. mandible normal tongue throat (pharynx) spine spinal cord salivary gland normal lymph nodes Cancer in Base of Tongue
  48. 51. PET Scan used to create radiation target PET Scan , showing cancer in right tongue Computer generated reconstruction, the target area is in red
  49. 52. Cancer (blue) surrounded by large field low dose radiation and then high dose boost field
  50. 53. Tomotherapy Shrinking field technique, the first phase covers a large area and the final boost phase is more targeted
  51. 55. Low risk parotid gland tumor (in red) may be possible to keep the radiation zone (blue) as small as possible , computer plan
  52. 56. Low risk parotid gland tumor, then using Tomotherapy to ensure coverage of the tumor on the left, but avoiding going too deep and hitting normal parotid on other side
  53. 57. Since Tomotherapy takes a CT scan daily prior to radiation it is often possible to observe the tumor shrinking during the course of the radiation
  54. 58. Seeing the cancer shrink during a course of Tomotherapy. Nasopharynx cancer after just 8 treatments Cancer mass Cancer mass Blue = radiation target
  55. 59. Squamous cell carcinoma in upper jaw behind left eye treated with Tomotherapy CT scan at 6 months cancer Radiation zone
  56. 60. For patients with dental work, a conventional CT (kV) will have artifact obscuring the anatomy that can be eliminated using the Tomo CT images (MV)
  57. 61. Lung Cancer
  58. 62. PET/CT Lung Cancer Image
  59. 63. Computer generated images will show how close the cancer is to other important structures (like the spinal cord, the heart and the liver, and how much normal lung is near
  60. 64. Using CT scans the computer can generate the target for a cancer in the upper part of the lung
  61. 65. Using CT scans the computer can generate the target for a small cancer growing inside the trachea
  62. 66. Computer generated images to target the tumor
  63. 67. Tomotherapy images showing the radiation zone in red surrounds the cancer area (in blue) and limits the dose of radiation that hits the normal lung, heart or spinal cord
  64. 68. Lung cancers shrink slowly during the radiation, this picture from the daily Tomo image shows good regression only half way through the course of radiation
  65. 69. CT Scan prior to radiation Tomo image after only 19 treatments cancer cancer Radiation and chemotherapy for NSCL, the mass may shrink significantly during the course of radiation
  66. 70. Adaptive Radiotherapy – adjusting the radiation target during treatment as tumor shrinks Tomotherapy Plan at start Tomotherapy Plan at finish
  67. 71. Dose as a Function of Lung Volume and Planned Treatment Volume in Helical Tomotherapy Intensity-Modulated Radiation Therapy-Based Stereotactic Body Radiation Therapy for Small Lung Tumors Joseph M. Baisden, M.D., Ph.D IJROBP Volume 68, Issue 4, Pages 1229-1237 (15 July 2007) Tomotherapy can be used for highly targetted intense radiation (radiosurgery)
  68. 72. Tomotherapy used for lung metastases
  69. 73. PET Scan showing complete remission of the cancer in the left lung at 7 months
  70. 74. PET scan showing near complete remission, 2 months after radiation alone for NSCL
  71. 75. PET scan showing degree of tumor shrinkage 6 weeks after completion chemoradiation for NSCL lung cancer (the tumor will continue to shrink for weeks to months)
  72. 76. Prostate Cancer
  73. 77. Cancer occurs along the outside edge of the prostate just under the capsule
  74. 78. Cancer occurs along the outside edge of the prostate just under the capsule
  75. 79. bladder Radiation zone prostate rectum Goal = radiation zone precisely around the prostate cancer
  76. 80. With Tomotherapy the beam can hit the target (nodes) in the upper abdomen and avoid the bladder and small intestine and lower in the pelvis hit the prostate, nodes and seminal vesicles and still avoid the bladder and rectum
  77. 81. Significant movement of the prostate gland based on daily gas in rectum Planned target Rectal gas No Rectal gas Planned target, missed badly if rectal gas pushes the prostate forward
  78. 82. Significant movement of the prostate gland based on daily gas in rectum Initial computer target for prostate (red circle) would have badly missed the target if no adjustments were made based on the amount of rectal gas
  79. 83. Importance of daily CT targeting on Tomotherapy and adjusting the treatment daily Very little bowel gas on initial study and the dose (red) targets the prostate gland closely large bowel gas on later treatment day and the dose (red) will cover half the rectum if an adjustment is Not made
  80. 84. If no adjustment was made Actual treatment on Tomotherapy
  81. 86. Using Tomotherapy to tightly target the prostate with very little radiation hitting the bladder or rectum
  82. 87. Tomotherapy is particularly useful in men with hip replacements where the metal creates artifacts in normal kv CT
  83. 88. Dose as a function of liver volume and planning target volume in helical tomotherapy, intensity-modulated radiation therapy–based stereotactic body radiation therapy for hepatic metastasis International Journal of Radiation Oncology, Biology, Physics   01 October 2006 (Vol. 66, Issue 2, Pages 620-625) TomoTherapy can be used for many other sites, e.g. liver metastases