A One Step Model for Online
 Planning and Treatment for
Palliative Radiotherapy using
        Cone Beam CT
   David Fitzpa...
Background
• Palliative radiation should be effective yet fast
• Uses simple Techniques
   – Ant/Post opposed fields
   – ...
Cone Beam CT (CBCT)
• CBCT scan images can be rapidly acquired
  on an RT treatment unit
• CBCT established for Image Guid...
Conventional CT Simulation (PCT)
        Planning and RT
        Time: Many Hours to 1-2 Days


   Volumetric Imaging

   ...
Conventional Planning Process
    PLANNING CT               PT WAITS FOR RT
EXPORT IMAGES TO TPS


          CONTOURING

 ...
Study Objective
     To Replace a multistep PCT process by a
  1 step 30 min appointment at the treatment unit.
A CBCT ena...
Methods
• Phase A
  – Is the image quality adequate for planning?
     • Spine, Mediastinum, Abdomen/Pelvis
     • Suitabl...
Methods
• Outcomes
  – Agreement between CBCT and PCT defined GTV
  – Adequacy of coverage of PCT generated PTV by
    CBC...
Phase A
                                      OVERCOVERAGE by CBCT v PCT
Spine or mediastinum or
   abdominal disease     ...
Phase A          GEOGRAPHIC AREA COMPARISON

                                       CBCT/PCT
            CBCT/DRR      PCT...
Phase B
          Spine
          Mediastinum      For Pall RT
          Abdomen/Pelvis




                  PCT plan
   ...
CBCT Plan vs PCT Plan

         Spine          Mediastinum/     Abdomen pelvis
                            lung
          ...
Phase B

• Adequacy of CBCT plan     CBCT plan 90% isodose line
  90% isodose coverage of
  PCT generated PTV
   - Spine -...
Phase B - Timing results


                CBCT
                                                     Planning CT
         ...
Phase B C
 Phase
   Bone only to date
                                          1 Step Process
       Mediastinum
        ...
Phase C Elapsed Time (10 spine patients)

                Task                                                 Time (min)
...
Phase C Total Elapsed Time (10 patients)
Satisfaction data
  1= strongly agree, 2 = agree, 3 neither agree/disagree, 4 disagree, 5 strongly disagree

             ...
Clinical Advantages of 1 Step Online
              Planning and Treatment

• 1 step (less handoffs)
• Time efficiency from...
Thank You for
Your Attention
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Palliative Radiotherapy Using Cone Beam Ct

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Palliative Radiotherapy Using Cone Beam Ct

  1. 1. A One Step Model for Online Planning and Treatment for Palliative Radiotherapy using Cone Beam CT David Fitzpatrick, Anita Vloet, Daniel Letourneau, Rebecca Wong, Mary Gospodarowicz, David A Jaffray 5th Annual Toronto Radiation Medicine Conference Kingbridge Sunday 27 April 2008
  2. 2. Background • Palliative radiation should be effective yet fast • Uses simple Techniques – Ant/Post opposed fields – A Direct field • Conventional CT planning – a multistep process – can take a few hours to 1-2 days • 2D planning – Quicker than CT planning – But lacks dosimetric information
  3. 3. Cone Beam CT (CBCT) • CBCT scan images can be rapidly acquired on an RT treatment unit • CBCT established for Image Guided RT Jaffray, Kupelian at al Expert Rev Anticancer Therapy 2007 • CBCT recently developed to permit image quality sufficient for treatment planning Letourneau, Wong et al IJROBP 2007. Sharpe, Moseley et al Med Physics 2006.
  4. 4. Conventional CT Simulation (PCT) Planning and RT Time: Many Hours to 1-2 Days Volumetric Imaging Planning QA and IGRT 3
  5. 5. Conventional Planning Process PLANNING CT PT WAITS FOR RT EXPORT IMAGES TO TPS CONTOURING PLANNING + DR APPROVAL PHYSICS QA QA ROOM WEB PUBLISHING EXPORT PLAN TO RT UNIT TREATMENT UNIT PT SET UP + IGRT PT HAS RT TREATMENT DELIVERY
  6. 6. Study Objective To Replace a multistep PCT process by a 1 step 30 min appointment at the treatment unit. A CBCT enabled Online Treatment Strategy Volumetric Imaging Online Planning QA Delivery and IGRT 3
  7. 7. Methods • Phase A – Is the image quality adequate for planning? • Spine, Mediastinum, Abdomen/Pelvis • Suitable for CT planning • n = 3x3 • Phase B – Trial on-line planning within the clinical environment – n = 45 (15 spine, 15 thoracic, 15 abdomen/pelvis) • Phase C – Testing the efficacy of the established on-line planning system to treat patients. – n = 60 (15 spine + 15 bone, 15 thoracic, 15 abdomen/pelvis)
  8. 8. Methods • Outcomes – Agreement between CBCT and PCT defined GTV – Adequacy of coverage of PCT generated PTV by CBCT plan 90% isodose – Time – Patient satisfaction rates
  9. 9. Phase A OVERCOVERAGE by CBCT v PCT Spine or mediastinum or abdominal disease CBCT For palliative RT Overlap Conventional Planning CT (PCT) Cone beam capable treatment unit PCT DRR UNDERCOVERAGE by CBCT v PCT
  10. 10. Phase A GEOGRAPHIC AREA COMPARISON CBCT/PCT CBCT/DRR PCT/DRR Mean ±SD% Mean ±SD% Mean ±SD% 46 ± 61 42 ± 47 11 % UC 31 ± 34 29 ± 34 11 % OC 57 ±17 57 ±16 80 % Overlap
  11. 11. Phase B Spine Mediastinum For Pall RT Abdomen/Pelvis PCT plan used to treat patient During 1 fraction of treatment a CBCTscan acquired images and CBCT study plan generated
  12. 12. CBCT Plan vs PCT Plan Spine Mediastinum/ Abdomen pelvis lung Field Area Field Area Field Area mean (SD) mean (SD) mean (SD) n = 13* n = 15 n = 16 % UC 12 (13) 18 (16) 20 (15) % OC 15 (21) 21 (24) 10 (13) % OL 89 (13) 82 (15) 80 (15)
  13. 13. Phase B • Adequacy of CBCT plan CBCT plan 90% isodose line 90% isodose coverage of PCT generated PTV - Spine - 93 + 11 % PTVPCT - Mediast – 89 + 15% - Abd/Pelvis – 92 + 5%
  14. 14. Phase B - Timing results CBCT Planning CT Patient or Planning CT Institution's Institution's perspective Patient's Perspective Perspective Total Time 28+/- 8 min 30 +/- 12 min 149 +/- 78 min
  15. 15. Phase B C Phase Bone only to date 1 Step Process Mediastinum Patient Set Up Abdomen/Pelvis PCT CBCT Image Acquisition Process: Exported to TPS Images Define PTV Cone beam scan GTV PCT Fields PCT Planning acquired on treatment unit and CBCT Time PCT Plan Published generated plan used to Pt satisfaction PCTPlan to RT unit Export treat patient Dr. Approval + QA IGRT CBCT Conventional Planning CT Treatment Delivery for Retrospective validation
  16. 16. Phase C Elapsed Time (10 spine patients) Task Time (min) Professional Patient Walk in and Setup 8.3 ± 2.2 MRT(T) CBCT Acquisition and Export 6.3 ± 2.1 MRT(T) and Planner Dr Contouring 3.4 ± 1.3 RO Planning / Export / WebPub 9.9 ± 3.0 Planner QA_Phys, RO and QA, Approval and CBCT #2 8.7 ± 2.6 MRT(T) Treatment Delivery 2.5 ± 0.5 MRT(T) Patient Walk out 2.3 ± 1.0 MRT(T) Total ------ 39.3 ± 6.8 MRT(T): Therapist, RO: Radiation oncologist and QA_Phys: QA physicist
  17. 17. Phase C Total Elapsed Time (10 patients)
  18. 18. Satisfaction data 1= strongly agree, 2 = agree, 3 neither agree/disagree, 4 disagree, 5 strongly disagree Median (Range) Previous XRT 4 Yes 3 no (3 NA) Planning and treatment process uncomfortable 4 (3-5) Inconvenient 4 (2-5) Process difficult 4 (4-5) Difficulty lying in position 3.5 (1-5) Took a long time 3.5 (2-5) Efficient 2 (1-5) Satisfied with care 1 (1-2)
  19. 19. Clinical Advantages of 1 Step Online Planning and Treatment • 1 step (less handoffs) • Time efficiency from Institutional perspective • Weekend on call – Minimize pt transfer between units when staff minimal – Do not require staff trained to operate both CT Simulator and RT treatment unit • Same day Sim + Treatment start • Minimize delays due to sequencing between systems • Could potentially be used in developing countries for 3D simulation and Planning
  20. 20. Thank You for Your Attention

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