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Total Body Irradiation (TTBI) treatments using a Tomotherapy unit: Feasibility, advantages, problems and prospects 1 G.Gui...
PLAN PARAMETERS – COMPARISON  (e.g. Size of the patient : Big) V 12 =93% Body (DMax=14Gy) V 8 <15% Lungs 1927 sec 58 2.5 0...
ISSUE AND CONSIDERATION <ul><li>FIELD WIDTH 2.5 CM </li></ul><ul><ul><li>Decreasing of the target dose distribution </li><...
PAEDIATRIC PATIENT <ul><li>Paediatric Patient : Small (<150cm) </li></ul><ul><li>Single Plan </li></ul><ul><li>Beam-ON: 11...
SMALL PATIENTS <ul><li>Size Patient : Small </li></ul><ul><li>Beam-ON: 1644 sec </li></ul><ul><li>2 Plans </li></ul><ul><u...
DQA (Delivery Quality Assurance) <ul><li>DQA </li></ul><ul><ul><li>3 Type </li></ul></ul><ul><ul><ul><li>Head (Eyes) </li>...
INNOVATIVE TECHNIQUES – (TLI AND TMI) <ul><li>TMI (Total Marrow irradiation) or TLI (Total Lymphoid Irradiation) are simil...
RESEARCH (DIODE QA) – PRELIMINARY RESULTS FOR HELICAL TREATMENT Preliminary Results ( G.Guidi - P.Ceroni ) Diode courtesy ...
ISSUES, LIMITATION AND TRICK <ul><li>Maximum Gantry rotation = 60 </li></ul><ul><li>Long beamlet time > 12 h/ plan using t...
CONCLUSIONS TTBI (Tomotherapy TBI) A FEASIBLE AND PROMISE TECHNIQUE FOR THE FUTURE <ul><li>The simulation of the patients ...
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Total Body Irradiation (Ttbi) Treatments Using A Tomotherapy Unit

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Total Body Irradiation (Ttbi) Treatments Using A Tomotherapy Unit

  1. 1. Total Body Irradiation (TTBI) treatments using a Tomotherapy unit: Feasibility, advantages, problems and prospects 1 G.Guidi, 2 M.Amadori, 2 P.Antognoni, 1 E.Cenacchi, 1 L.Morini, 1 L.Boni, 1 P.Ceroni, 2 G.Tolento, 2 G.De Marco, 2 S.Scicolone, 2 M.Parmiggiani, 2 P.Giacobazzi, 2 S.Pratissoli, 2 F.Titone, 2 B.Lanfranchi, 1 C.Danielli, 2 F.Bertoni, 1 T.Costi, *M.Corni 1 Medical Physics 2 U.O. Radiation Oncology Azienda Ospedaliero - Universitaria di Modena - Policlinico Acknowledges : *In memory of Marco Corni, whose contribution of professionalism, consistency, helpfulness and friendliness are been crucial for development, obtaining and comparing the present results.
  2. 2. PLAN PARAMETERS – COMPARISON (e.g. Size of the patient : Big) V 12 =93% Body (DMax=14Gy) V 8 <15% Lungs 1927 sec 58 2.5 0.385 5 cm V 12 =93% Body (DMax=14Gy) V 8 <20% Lungs 1972 sec 55 2.5 0.400 5 cm 60 52 Gantry Rotations 3155 sec 1956 sec Delivery Time <ul><li>V 8 <1% Dummy Lungs (Lungs contracted laterally by 0.5cm to guaranties the irradiation of the body during the breathing) </li></ul><ul><li>V 9 <1% Lens </li></ul><ul><li>Dose Prescription 12Gy @ 93%Vol </li></ul><ul><li>Other MF (e.g MF = 3.5, 5, 7) and Pitch (e.g. P=0.35, 0.287, 0.213) are applicable for optimization but the system is crashed during the Final Dose Calculation or the “Get Full Dose” </li></ul>V 12 =93% Body(DMax=15Gy) V 8 >40% Lungs 1.8 0.875 2.5 cm V 12 =93% Body (DMax=14Gy) V 8 <25% Lungs 2.5 0.415 5 cm DVH Highlight MF Pitch Field Width
  3. 3. ISSUE AND CONSIDERATION <ul><li>FIELD WIDTH 2.5 CM </li></ul><ul><ul><li>Decreasing of the target dose distribution </li></ul></ul><ul><ul><li>Increasing of the treatment time </li></ul></ul><ul><ul><li>Increasing of the lungs doses </li></ul></ul><ul><ul><li>Increasing of the lungs doses </li></ul></ul><ul><ul><li>Arms and lateral extremity receive less dose than prescription due to the rotation </li></ul></ul><ul><ul><li>Lung receive more doses </li></ul></ul><ul><ul><li>Maximum of dose > 115% Dp </li></ul></ul><ul><li>LEGS </li></ul><ul><ul><li>Marker at 1/3 of the femur is used to define the beams or to avoid any beams overlap ore over dosage </li></ul></ul><ul><ul><li>Inferior extremity are treatable using </li></ul></ul><ul><ul><ul><li>2 opposed filed at the Linac with calculation at the middle-plane </li></ul></ul></ul><ul><ul><ul><li>Using Helical treatment is also possible to treat </li></ul></ul></ul><ul><ul><ul><li>Probably using Direct Beam Option could be possible to save time </li></ul></ul></ul>
  4. 4. PAEDIATRIC PATIENT <ul><li>Paediatric Patient : Small (<150cm) </li></ul><ul><li>Single Plan </li></ul><ul><li>Beam-ON: 1150 sec </li></ul><ul><li>Dose Distribution: </li></ul><ul><ul><li>Prescription 12 Gy @ 93%Vol </li></ul></ul><ul><ul><li>Max Dose <110% Dp </li></ul></ul><ul><ul><li>Lung : V8 > 20% </li></ul></ul><ul><ul><li>Lens < 3Gy </li></ul></ul><ul><li>Integral doses and high dose rate must be evaluate before to treat paediatric patients with this techniques </li></ul><ul><li>Special case not treatable using standard TBI could be submitted or evaluated by ethic committee, before to be treatable using Tomotherapy TBI </li></ul><ul><li>Many open issue at the moment must be consider before to treat paediatric patients, but the techniques could be important, especially considering the comfort, accuracy and the speed of the procedures </li></ul>
  5. 5. SMALL PATIENTS <ul><li>Size Patient : Small </li></ul><ul><li>Beam-ON: 1644 sec </li></ul><ul><li>2 Plans </li></ul><ul><ul><li>Body (Head - 1/3 Femur) </li></ul></ul><ul><ul><li>Legs (From 1/3 Femur) </li></ul></ul><ul><li>Beam-ON: 1644 sec </li></ul><ul><li>Dose Distribution: </li></ul><ul><ul><li>Prescription 12 Gy @ 90%Vol </li></ul></ul><ul><ul><li>Max Dose <110% Dp </li></ul></ul><ul><ul><li>Lung : V8 < 40% </li></ul></ul><ul><ul><li>Dummy Lung : V8 < 10% </li></ul></ul>
  6. 6. DQA (Delivery Quality Assurance) <ul><li>DQA </li></ul><ul><ul><li>3 Type </li></ul></ul><ul><ul><ul><li>Head (Eyes) </li></ul></ul></ul><ul><ul><ul><li>Lung area </li></ul></ul></ul><ul><ul><ul><li>End Region of the treatment to guarantee the complete treatment of the patient </li></ul></ul></ul><ul><li>Cheese Phantom </li></ul><ul><ul><li>Gafchromic + Ion Chamber </li></ul></ul><ul><li>Map Comparing </li></ul><ul><ul><li>Vidar Dosimetry Pro 16 </li></ul></ul><ul><ul><li>Gamma Index (3% @ 3mm) </li></ul></ul><ul><ul><ul><li>Actual results <1% of differences </li></ul></ul></ul><ul><li>Dose Profile evaluations </li></ul><ul><ul><li>Matching of the profile on X and Y direction </li></ul></ul>
  7. 7. INNOVATIVE TECHNIQUES – (TLI AND TMI) <ul><li>TMI (Total Marrow irradiation) or TLI (Total Lymphoid Irradiation) are similarly applicable using Helical Treatment </li></ul>
  8. 8. RESEARCH (DIODE QA) – PRELIMINARY RESULTS FOR HELICAL TREATMENT Preliminary Results ( G.Guidi - P.Ceroni ) Diode courtesy of Tema Sinergie
  9. 9. ISSUES, LIMITATION AND TRICK <ul><li>Maximum Gantry rotation = 60 </li></ul><ul><li>Long beamlet time > 12 h/ plan using the DC2/DC3 Cluster </li></ul><ul><li>Long Optimization Time ~ 1-1.5min per iteration ( 200-300 iterations per plan) </li></ul><ul><li>Image resample 256 x 256 can completely adequate for small volume (e.g. lens) </li></ul><ul><li>Dose Matrix Volume (0.642cm) – Why should I use Gamma Index of 3mm @ 3%? </li></ul><ul><li>Prescription? </li></ul><ul><ul><li>12 Gy @ 93% of the volume </li></ul></ul><ul><ul><li>Dmean = 12 Gy (Easy way to plan and obtain DVH results, but a careful analysis of the volume is necessary) </li></ul></ul><ul><li>Many immobilization devices and setup are been explored, but the most reproducible is the supine position with a Vacuum device. The patient head should be fixed but the mouth should be freedom </li></ul><ul><li>20-25 minutes to “Get the full doses” </li></ul><ul><li>20-25 minutes to calculate the final dose </li></ul><ul><li>3 h to prepare the 3 DQA Plans (Head, Lung, Cauda) </li></ul><ul><li>3 h of beams to perform the QA at the machine (MVCT + DQA for each DQA Plan) </li></ul><ul><li>Liver, spleen and heart should be used as a Target, during the plan optimization, to dose the body adequately close to the lungs, otherwise some area will be significantly under dosed </li></ul><ul><li>Hot-Spot must be controlled, but increasing the MF could be not possible to deliver the plans due to the machine constrain (Time, Gantry Speed Rotation, Beam undeliverable) </li></ul><ul><li>Using the prescription at the mean dose the plan is very easy and fast but few area of the marrow or the body could be completely under dosed (Preliminary results) </li></ul>
  10. 10. CONCLUSIONS TTBI (Tomotherapy TBI) A FEASIBLE AND PROMISE TECHNIQUE FOR THE FUTURE <ul><li>The simulation of the patients has demonstrated the feasibility and advantages of treatments TTBI </li></ul><ul><ul><li>20-30min of beam-on </li></ul></ul><ul><ul><li>Supine position </li></ul></ul><ul><ul><li>Reposition the patient through the use of IGRT techniques </li></ul></ul><ul><ul><li>The technology allows to treat patients, with clear benefits identified in the best coverage of the target and the OAR sparing </li></ul></ul><ul><li>We have identified some problems and limits to the research subject. </li></ul><ul><ul><li>Some considerations, still subject of evaluation </li></ul></ul><ul><ul><ul><li>Immobilization systems </li></ul></ul></ul><ul><ul><ul><li>Computation time </li></ul></ul></ul><ul><ul><ul><li>DQA-Quality </li></ul></ul></ul><ul><ul><ul><li>Vivo Dosimetry using Diode or Mosfet </li></ul></ul></ul><ul><ul><ul><li>TTBI Dose Rate (800 cGy / min) compared with conventional treatments TBI (10-40 cGy / min). </li></ul></ul></ul><ul><ul><li>Features of research </li></ul></ul><ul><ul><ul><li>Irradiate mice </li></ul></ul></ul><ul><ul><ul><ul><li>To evaluate teh high dose rate effect in lung and OARs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>To highlight changes on stem cells and influence on cells in transit through the blood. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Explore differential fractionation scheme (eg, 16-18Gy) based on radiobiological evidences </li></ul></ul></ul></ul><ul><li>Similarly to the results of Total Marrow Irradiation (TMI) and Total lymphoid Irradiation (TLI), the Tomotherapy TBI (TTBI) could be considered an innovative technique applicable to the clinical routine . </li></ul><ul><li>Finally some doubts are expressed in emergency management , where you may need to find a Tomotherapy backup or develop a similar treatment, to ensure continuity therapeutic even during maintenance of the equipment. </li></ul>

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