Imrt Symposia Global Overview

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Imrt Symposia Global Overview

  1. 1. IMRT: Global View Arno J. Mundt MD Professor and Chair Department of Radiation Oncology University of California San Diego, La Jolla CA
  2. 2. A Walk Down Memory Lane
  3. 3. “…further refining of delivery technology and the inverse planning system, gaining clinical experience to address target definition and dose inhomogeneity within the targets, and understanding the partial volume effect on normal tissue tolerance are needed for IMRT to excel in the treatment of head and neck cancer….”
  4. 4. Today IMRT is no longer a “new” or “novel” technology IMRT has literally “grown up” Pre-IMRT era seems like a long time ago
  5. 5. IMRT A major revolution in our field Fundamentally changed the way we plan and deliver radiation therapy
  6. 6. IMRT Revolution “There are no non-violent revolutions…” Malcolm X Resulted in the upheaval of the daily lives of all of us (physicians and medical physicists alike)
  7. 7. IMRT Revolution Proposed over 40 years ago by Takahashi in Japan Takahashi et al. Acta Radiol 1965;242 1st attempted in the late 1960s by Hellman and colleagues (JCRT) Deemed infeasible due to excessive planning and delivery times
  8. 8. IMRT Implementation In mid-1990s, IMRT began to be used at select academic centers Not till the late 1990s with the availability of commercial treatment planning systems did IMRT start to become widely available Currently, 10 commercial planning systems and 7 commercial delivery systems
  9. 9. Commercial Planning Systems BrainLAB (brainlab.com) BrainScan CMS, Inc. (cmsrtp.com) Xio IMRT Elekta (elekta.com) PrecisePlan NOMOS (nasmedical.com) CORVUS Philips (medical.philips.com) Pinnacle-PRO Prowess Inc (prowess.com) Panther DAO RAHD (rahd.com) 3D/Pro, Konrad Siemens (siemens.com) Konrad Tomotherapy (tomotherapy.com) Hi-Art Varian (varian.com) Eclipse Hamilton et al. Treatment Planning IMRT: A Clinical Perspective. Mundt A, Roeske J (editors) BC Decker, Toronto, 2005
  10. 10. Commercial Delivery Systems brainlab.com BrainLAB elekta.com Elekta nasmedical.com NOMOS Southeastern Radiation seradiation.com Products siemens.com Siemens tomotherapy.com Tomotherapy varian.com Varian Saw C, Ayyangar K, Krishna K, Wu A, Kalnicki S Delivery Systems IMRT: A Clinical Perspective. Mundt A, Roeske J (editors) BC Decker, Toronto, 2005
  11. 11. What is the Current Level of IMRT Use?
  12. 12. IMRT Surveys Two surveys performed to assess the level of IMRT use in the United States 2002 Survey (450 Radiation Oncologists) Mell LK, Roeske JC, Mundt AJ. Cancer 2003;204-211 2004 Survey (500 Radiation Oncologists) Mell LK, Mehrotra AK, Mundt AJ. Cancer 2005;104:1296-1301
  13. 13. IMRT Surveys Adoption was at first slow, but later occurred at a very rapid rate In the 2002 survey, 32% of radiation oncologists were using IMRT In the 2004 survey, this percentage increased to 74%
  14. 14. Cumulative IMRT Adoption (USA) 100% 90% 80% Percent of Physicians 70% 60% 50% 40% 30% 20% 10% 0% 1992 1995 1998 2001 2004* *As of 8/04 Year Mell LK, Mundt AJ. Survey of IMRT Use in the USA - 2004 American Radium Society Barcelona Spain 2005
  15. 15. IMRT Adoption Initially only used at a few academic institutions with home-grown systems With advent of commercially available planning systems, tremendous adoption seen in private practice community
  16. 16. IMRT Utilization Private and Academic Physicians 100% 90% 80% 80% 70% 71% 60% Private 50% 47% 40% Academic 30% 23% 20% 10% 0% 2002 2004 P = 0.14 P = 0.003
  17. 17. IMRT Utilization Wide variety of sites are now being treated Top 3 Prostate, Head and Neck, CNS In recent years, increasing interest in other sites Gynecology, GI, Breast
  18. 18. IMRT Practice Survey (2004) Top Treated Sites Site % __ Prostate 85% Head and Neck 80% CNS 64% Gynecology 35% Breast 28% GI 26% Sarcoma 20% Lung 22% Pediatrics 16% Lymphoma 12% Mell LK, Mundt AJ. Survey of IMRT Use in the USA- 2004 Cancer 2005;104:1296
  19. 19. IMRT Use While commonly available, it is being used to treat only a subset of patients at most centers Rarely used in a large percentage of patients under treatment
  20. 20. IMRT Use 100% Majority of IMRT 80% users (73%) treat 60% <1/4 of their 40% patients with IMRT 20% <5% use it in >1/2 of their current 0% % Percentage patients <25% 25-50% 51-75% >75%
  21. 21. Clinical Impressions 2004 Survey asked clinical impressions of IMRT users Overwhelmingly favorable Most only able to comment on acute toxicity Few could comment on chronic toxicity or tumor control
  22. 22. Acute Toxicity Most (87%) felt 50 acute toxicity was 45 similar or better 40 than conventional 35 30 RT 25 13% felt it was 20 worse (primarily in 15 head/neck cancer*) 10 5 *many of these also reported 0 ↓acute toxicity in prostate pts Better Same Worse
  23. 23. Chronic Toxicity 55% could assess chronic toxicity 80 70 Of these, great majority (73%) felt 60 it was better than 50 standard RT 40 Only 1 felt it was 30 worse 20 10 No 2nd tumors noted (even among 0 Better Same Worse long-term users)
  24. 24. Tumor Control 60 47% could assess tumor control 50 Of these, the 40 majority felt it was 30 superior or similar 20 None felt it was worse 10 0 Better Same Worse
  25. 25. Future IMRT Use IMRT use will continue to grow Majority of current radiation oncology residents are taught IMRT Survey of Chief Residents at 77 programs → 87% hands on experience >50% planned and treated >25 IMRT pts Wide variety of tumor sites Malik R, Mundt AJ et al. Survey of Resident Education in IMRT Technol Cancer Res Treat 2005;4:303-309
  26. 26. Disease Sites Treated Resident Survey Site % Head and Neck 92% Prostate 81% CNS Tumors 56% Pediatrics 38% Gynecology 24% Recurrent/Palliative 24% Breast 21% GI 21% Lung 15% Lymphoma 7%
  27. 27. Why is IMRT so popular????
  28. 28. Cynical Answer $$$$
  29. 29. Reasons for Adopting IMRT Normal Gain Tissue Escalate Competitive Remain Advantage Competitive Sparing Dose 100 90 92% 80 89% 70 60 50 Research 40 30 38% 36% Other* 20 10 10% 0 1 2 3 4 5 6 *”…don’t all boys love new toys?”
  30. 30. Motivations Financial reasons are common New billing codes added in 2001 making reimbursement 4 times conventional In 2004, reimbursement rates revised down to 2.8 times conventional RT
  31. 31. Financial Motivations Led some physicians to make false claims about IMRT Internet is full of such misinformation Review of IMRT websites → 42% have false and/or misleading information (including many academic sites!) Schomas D, Mell LK, Mundt AJ. IMRT and the Internet: Evaluation of Content and Quality of Patient-Oriented Information Cancer 2004;101:412-20
  32. 32. Example Statements Conventional prostate RT can leave the patient impotent and incontinent…IMRT dramatically decreases these problems IMRT is a kindler and gentler treatment because it leaves healthy tissues alone IMRT beams intersect on the tumor by turning corners The promise of IMRT lies in its ability to focus treatment only on the tumor
  33. 33. Why is IMRT so popular???
  34. 34. Less Cynical View Improves sparing of normal tissues, reducing the risk of acute and chronic sequelae → Improving patient quality of life Improves ability to dose escalate high risk patients, cover of difficult targets and even safely re-irradiate patients → Improving tumor control
  35. 35. And Importantly….. IMRT rests on an ever growing foundation of convincing clinical data
  36. 36. IMRT Literature Initially devoted exclusively to physics issues, e.g. tongue and groove effect, QA, etc. Clinical studies have become increasingly common in recent years
  37. 37. IMRT Clinical Studies* 559 364 (65%) 195 (35%) Dosimetric Outcome *as of 1/1/07
  38. 38. IMRT Clinical Studies 160 140 120 100 80 60 40 20 0 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
  39. 39. 0 20 40 60 80 100 120 140 160 180 200 H ea d/N e ck P ro s ta t e B re a s t C NS G yn e L un g GI P ed s S ar co m IMRT Clinical Studies a O th e r
  40. 40. IMRT Outcome Studies 100 90 80 70 60 50 40 30 20 10 0 er S k st I e ds te G ec yn CN ea th ta Pe /N G os O Br ad Pr He
  41. 41. Clinical Studies 160 140 120 100 80 60 40 20 0 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 Larger series Early Small Series Longer follow-up Very limited follow-up Wide variety of disease Mostly prostate and sites head/neck
  42. 42. Every Red J now has IMRT outcome studies Mackley et al. IMRT for pituitary adenomas: preliminary report of the Cleveland Clinic Experience Daly et al. IMRT for malignancies of the nasal cavity and paranasal sinuses Bossi et al. IMRT for preoperative posterior abdominal wall irradiation of Retroperitoneal liposarcomas
  43. 43. Lessons from the Literature A number of reports highlight various issues/problems/toxicities in IMRT patients Such reports improve the quality and delivery of IMRT Teach us how to do IMRT and how not to do it
  44. 44. Mundens et al. (MD Anderson) Radiation Injury to the liver after IMRT in patients with mesothelioma: An unusual CT appearance AJR 2005;184:1091-5 Lee N et al. (UCSF) Skin toxicity due to IMRT for head/neck cancer Int J Radiat Oncol Biol Phys 2002;53:630-7 Uy et al. (Baylor) IMRT for meningioma Int J Radiat Oncol Biol Phys 2002;53:1265-7 De Neve W et al. Lethal pneumonitis in a phase I study of chemotherapy And IMRT for lung cancer Radiother Oncol 2005
  45. 45. And a cautionary note…….
  46. 46. IMRT Studies Prospective cooperative group trials evaluating IMRT are now appearing Most importantly, Phase III clinical trials are being undertaken
  47. 47. ASTRO Meeting 2006 Philadelphia
  48. 48. “IMRT Era” Truly an exciting time for IMRT Becoming standard in many disease sites Also being used in ever more sophisticated ways
  49. 49. IMRT will become increasingly common in the treatment recurrent disease Stephanie Milker-Zabel (Heidelberg) IMRT for Recurrent Spinal Metastasis IMRT: A Clinical Perspective BC Decker 2005
  50. 50. Electron IMRT Isodose distribution of a parotid cancer planned with electron IMRT ↑conformity and sparing of underlying tissues Song Y, Boyer A, Xing L et al. (Stanford) Modulated Electron Radiation Therapy IMRT: A Clinical Perspective BC Decker 2005
  51. 51. “Repair” of Unacceptable Brachytherapy Prostate Implants Original Brachy IMRT Brachy + IMRT Li XA, Wang JZ (U Maryland) Repair of Unacceptable Implants IMRT: A Clinical Perspective BC Decker 2005
  52. 52. Replacement of Brachytherapy Cervical Cancer Applicator-Guided HDR IMRT Low DA (Washington U) Applicator-Guided IMRT IMRT: A Clinical Perspective BC Decker 2005
  53. 53. Accelerated Concomitant Boost IMRT Breast Cancer Whole breast: 40.5 in 2.7 Gy fractions per day Lumpectomy Site: 48 Gy in 3.2 Gy fractions per day Tot al time = 3 weeks (15 fx) Eugene Lief, Silvia Formenti (NYU) Accelerated Concomitant Boost IMRT IMRT: A Clinical Perspective BC Decker 2005
  54. 54. Proton IMRT IM-proton plan in a 10 year old girl with a lumbar chordoma Lomax A Intensity Modulated Proton Therapy IMRT: A Clinical Perspective BC Decker 2005
  55. 55. Revolution Continues IMRT Image Guided IMRT Varian Trilogy
  56. 56. But one must always remember to keep an eye on the ball
  57. 57. Key to Successful IMRT Optimal Target Delineation
  58. 58. The value and importance of conferences such as these will never diminish…..
  59. 59. Thank You Enjoy the Conference

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