2009 emea 4d tomotherapy

04/08/23 G.GUIDI - M.AMADORI : 4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE EFFECTS OF THE TARGET MOTION 1

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EMEA 2009 Tomotherapy User Meeting

4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE

EFFECTS OF THE TARGET MOTION

G.Guidi1, M.Amadori2, E.Cenacchi1, L.Morini1, C.Danielli1, F.Bertoni2

1 Medical Physics Dpt.2 U.O. Radiation OncologyAzienda Ospedaliero - Universitaria di Modena - Policlinico

“… under the “Ghirlandina” Tower….…..new opportunities and ideas are growing

……and many people are working on it”


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CLINICAL RESEARCH – INTERCOMPARISON – TRIALS (TO ACQUIRE TOMOTHERAPY)

1. NSCLC : Efficacy and tolerances of exclusive and post-surgery radiation therapy treatments with/without chemo association, using CT-PET and Dynamic IMRT. Patients survivor and/or time progression analysis. Procedures and cost-benefit evaluation. (Prof. L.Fabbri, Prof. U.Morandi, Prof. B.Bagni, Dr. F.Bertoni, Dr. C.Danielli)

2. H&N : Radical treatments with chemo association using Dynamic IMRT, IGRT and Adaptive Radiation Therapy. Treatment conformity index, patients tolerance, efficacy and cost-benefit evaluation using Tomotherapy (Prof. P.F.Conte, Prof. A.Falchi, Dr. F.Bertoni, Dr. C.Danielli)

3. TBI (National Health Research - PIO V): Clinical and dosimetric evaluation of Total Body Irradiation using Tomotherapy. Transplant procedure, adequacy and safety evaluations of the treatments using Tomotherapy. Problem solving, efficacy and efficiency. (Prof. G.Torelli, Dr. F.Bertoni, Dr. C.Danielli)

4. PAEDIATRIC : Clinical evaluation of paediatric treatments. Paediatric patients management and performance assessment for high conformal and complex treatment using Tomotherapy. Clinical advantages and disadvantages. (Prof. P.Paulucci, Dr. F.Bertoni, Dr. C.Danielli)

5. BRAIN : Clinical study for upper-tentorial cerebral treatment using Tomotherapy. Clinical advantages and disadvantages, cost-benefit impact and patient management (Prof. G.Pinna, Dr. L.Mavilla, Prof. B.Bagni, Dr. F.Bertoni, Dr. C.Danielli)

6. TECHNOLOGY ASSESSMENT: Technical, dosimetric and cost-benefit evaluation of a Tomotherapy Unit. Routine applicability in a Public hospital for high conformal, IGRT and Adaptive Radiation Therapy treatment. Develop and optimization of treatment delivery, commissioning and Quality Assurance procedures. Time estimation and requirement to implement protocols and techniques (Dr. F.Bertoni, Dr. C.Danielli, Dr. Eng. M.Lugli)

TRIALS AND INTERCOMPARISON• IRMA – Partial Breast Irradiation (www.irmatrial.it)• CHPLT2008 A- H&N Multicentric Intercomparison • MESOTHELIOMA (Intercomparison IMRT vs. Tomotherapy vs. Protons)• NSCLC – Intercomparison CNAO (Photons - Protons)


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LET’S START FROM WHO HAS MORE EXPERIENCES THAN US


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RADIATION ONCOLOGY WORKFLOW ANALYSIS

Multi-modality Imaging

Immobilization

Verify and Monitor Delivery

Deliver Treatment

Pre-Verify Dose/Position

Simulation

Forward PlanningTreatment setup

Dose computation

Inverse PlanningDefine Objectives

Optimize

Plan Analysis

Dose Accuracy

Target and Structure Definition

Image Patient

Adaptive Analysis

Delivery System QA

Export to Delivery System

Pretreatment CT Guidance

Modify Plan/Patient Position

Planning

4D Components

Delivery

Export for Population


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4D WORKFLOW ANALYSIS (4D TOOLS AND ISSUES)


Immobilization


Deliver Treatment


Simulation


Dose computation


Optimize

Plan Analysis

Dose Accuracy


Image Patient

Adaptive Analysis

Delivery System QA




Planning

4D Components

Delivery


4D Images (>1000)

4D Tools & Issues

4D ContouringPropagate ROIs?MIP Contouring?4D OARs Volume Deformations

4D Planning (0-100% Phases)?4D Dose Computation – Phases?

4D Analysis (Multiple Plan)

4D QA (Dynamic Phantom)

4D Gamma Index?4D Dose Point?4D Edge Profile?Accuracy?

4D Inverse Planning(Same results?)

Which Plan or Phases?

Which Phases to be consider?

Trigger Tomotherapy is possible?

4D-MVCT?

Tracking the delivery

4D Adaptive RT Reconstruction


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4D WORKFLOW ANALYSIS - IMAGING & CONTOURING

Immobilization


Deliver Treatment


Simulation


Dose computation


Optimize

Plan Analysis

Dose Accuracy


Image Patient

Adaptive Analysis

Delivery System QA




Planning

4D Components

Delivery


4D Images (>1000)

4D Tools & Issues



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4DCT AND GATING/TRACKING DEVICES(TOSHIBA + VISION RT)

Advantages:4DCT Exams (10 CT Dataset – 0-100% Breathing Phases): Very Fast (few minutes) – Retrospective ModeRange Slice thickness for our RT: 0.5 - 3 mm (5mm used for Cranio Spinal Irradiation and TBI)VisionRT detect capability: 1-2mm of the couch movement (VisionRT can appreciate the ramp up of the couch during the CT scan)Issues:4DCT Images Reconstruction (>1000 Images – 10 CT Datasets – 5/6 Hours of reconstruction)Thickness 0.5mm could be useful for Radiosurgery but dose issues and the Tomotherapy image resample (256x256) could create problemsTroubles and investigation:Mismatch image reconstruction due to the couch ramp-up and the breathing signal (Sinogramma Editing in develop by Toshiba)Limited Trigger Time of 10 cycles/min not applicable (No idea why ????)Work on Phases 20-60% (5 CT Datasets) - 2-3mm Slice ThicknessContour all CTVs and OARs using TPS (Not Applicable).During routine is contouring Min exhale and Max inhale phases, but is no equal to contour the CTVs for each phases


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PINNACLE 4D RESEARCH CONSOLE

Contouring Objectives:Define contours that include all the organ and tumor movements due to the cyclesIssues:Contouring each phases is very long time consuming using standard TPS Advantages using Pinnacle 4D Console:Contouring the CTVs of the Multiple Phases (20-60%) and propagate ROI and OARs to all others 4DCT examsUse the Model Based Segmentation to speed up the contouring time Create an average MIP exams to accelerate the evaluation of the volumesCreate an ITV as integration of all the CTVs contoured in each phases

Beta Test Console: Courtesy of TA Tecnologie Avanzate

CT Movement Artifact(Lung or Liver)


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FOCAL 4D RESEARCH CONSOLE

Contouring Objectives:Define contours that include all the organ and tumor movements due to the cyclesIssues:Contouring each phases is very long time consuming using standard TPSAdvantages using Focal 4D Console:Contouring the CTVs of the Multiple Phases (20-60%) using MIP CineContouring on axial, coronal and sagittal viewPropagate ROI and OARs to all others 4DCT examsCreate an ITV as integration of all the CTVs contoured in each phases

Beta Test Console: Courtesy of TEMA Sinergie


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4D WORKFLOW ANALYSIS – PLANNING & DOSE COMPUTATION

Immobilization


Deliver Treatment


Simulation


Dose computation


Optimize

Plan Analysis

Dose Accuracy


Image Patient

Adaptive Analysis

Delivery System QA




Planning

4D Components

Delivery


4D Images (>1000)

4D Tools & Issues






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Simulation of a 4D Lung treatmentCreate beamlets and plans for each phases and CTVs contoured (Total of 5 plans + 1 Plan for the ITV)Comparison of the multiple plans calculated on the CTVs vs. plan on the ITVQuestions?If I don’t use any margin to the CTV?Suspected under dosage of the ITV without 4D evaluation of the CTV or to the Target in general

ITV

CTV

4D PLANNING & 4D DOSE COMPUTATION

Question?

• Are there any clinical issues due to the target motion?

• Any implication on boost or BTV contoured without target motion evaluation?

• Any missing during a stereotactic treatment?

• Can I reduce CTV or ITV margins with Tomotherapy?


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4D MULTIPLE PLAN EVALUATION

CTV20 (phase 20%)CTV30 (phase 30%)CTV40 (phase 40%)CTV50 (phase 50%)CTV60 (phase 60%)

ITV (phase 20%)ITV (phase 30%)ITV (phase 40%)ITV (phase 50%)ITV (phase 60%)

Upper Lobe Lesion & Small Volume 40% of Dose differences between CTV and ITV ...Question? Do I need a margin? Are enough accurate the voxel dimension for a 4DRT? (256x256)?

• Export Tomo Doses to CERR and process it• Long time consuming, but it is possible to evaluate and analyze multiple plan at the same time

CERR: Courtesy of Prof. Joseph Deasy – Prof. Issam El Naqa

Phase Dose Matrix Structure

Phases Dose Maps


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4D MARGIN EVALUATION (4 PLANS : TARGET=PTV)

PTV=CTV

PTV=ITV

PTV=CTV+0.5cm

PTV=CTV+ 1cm

Suspected CTV Voxel Issue correlated to the dose grid or to the image resample : Under investigation

CTV

ITV

CTV

ITV

CTV

ITV

CTV

ITV


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4D DOSE RECONSTRUCTION OF THE RESPIRATORY PHASES(Possible!!! But I will be crazy, if it will be a clinical routine (3 days of work))

4D DOSE RECONSTRUCTION

Dose Matrix (Phase 20%) +Dose Matrix (Phase 30%) +Dose Matrix (Phase 40%) +Dose Matrix (Phase 50%) +Dose Matrix (Phase 60%) +------------------------------------4D Dose Reconstruction

The breathing sinogramma will define the time (BIN) for each Dose Matrix


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4D QA

Immobilization


Deliver Treatment


Simulation


Dose computation


Optimize

Plan Analysis

Dose Accuracy


Image Patient

Adaptive Analysis

Delivery System QA




Planning

4D Components

Delivery


4D Images (>1000)

4D Tools & Issues







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Preliminary dosimetric issue of the Patient DQA using QUASAR PhantomRespiratory phases 15 cycles/min Active Target Simulation : 0.5 cm movement (Cranio – Caudal) during Tomo deliveryThe dynamic phantom has a dedicated Gaf-Chromic and Ion chamber insertDosimetric differences appraisal using Gaf-Chromic Film

X Coordinate: Edge of the CTV near the Gantry Y Coordinate: CTV Coronal Profile

LET’S GO TO THE QA AND ANALYZE THE REAL DOSES DELIVERED (DQA)THEORY AND PRACTICE COULD BE DIFFERENT

Dose measured and calculated are different and shifted, especially near the tumor edgesGamma Index 3%@3mm can help me ?

Calculated : 2.25 GyMeasured : 1.75 Gy


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4D GAF CHROMIC ANALYSIS (GAMMA INDEX 3% @ 3mm)

Inside the target seems to be delivered an adequate dose..... but the dose at the border of the target looks very different from the

plan

Calculated : 2 Gy

Measured : 1.75 Gy

Can I accept the DQA?1. X - Y direction are not adequate2. Z –Y direction analysis can be

done using same method3. X-Y-Z direction at the same time

....not at the moment with this phantom


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Which dose we deliver to the BTV (e.g. SIB or BTV Boost), without any extra margin.........maybe some active cancer cells inside, could be underdosed

Currently we are using PET for target definition, but we should evaluate the 4D CT/PET information•BTV definition•ITV definition (IBTV : Internal Biological Target Volume)•Windows Thresholds•Type of tracer•......

QUESTION ?WHICH IS THE DOSE DELIVERED DURING A BOOST OF THE BTV AND THERE ARE NO MARGINS OR ITV EVALUATION?

4D CT/PET : Work in progress

ITVCTV

4D CT/PET : Different case


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Preliminary results using a dynamic Phantom (Quasar) Respiratory phases 15 cycles /minThe easiest sinogramma (periodic and constant - sinusoidal)Evaluate Cranial Caudal direction AnalysisTarget Movement: 1 cm

EVALUATE THE RESULTS

LET’S GO BACK TO PHANTOM AND LET’S TRY TO SIMPLIFY THE PROBLEMS

4D Motion Artifact(Should be a circle)

Equal Workflow but in a Phantom1. Acquire a4DCT Exams of the phantom2. Contour and define the inserts objects for each phases (Cube and

Spheres)3. Create multiple plan4. Evaluate the dose delivered using Gaf and Ion Chamber5. Analyze the easiest problem

EASY ANALYSIS CONDITIONDefined Direction

Defined Structures Revolutions and MovementsRigid Phantom

Defined Sinogramma


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Preliminary results using a dynamic Phantom (Quasar) Respiratory phases 15 cycles /minCranial Caudal direction Analysis (4D Phantom can’t permit to analyze the X,Y,Z coordinate at the same time)Target Movement: 1 cmMorphing of the structures (4D Issue and Investigation)

Dosimetric impact of the structure morphing

due to respiratory motionDose Shift 1cm

Cranial under dosage and caudal over-dosage should be consideredDosimetric results on Gaf-Chromic: shift of 1cm (Cranial Caudal direction)

MODERATE DOSE DIFFERENCESBUT GAMMA INDEX AND DOSE ACCURACY NOT ACCEPTABLE FOR A PATIENT TREATMENT

TRY TO SIMPLIFY THE PROBLEMS .... VERY SIMILAR RESULTS

Gamma Index due to respiratory motion


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4D ADAPTIVE RADIATION THERAPY

Immobilization


Deliver Treatment


Simulation


Dose computation


Optimize

Plan Analysis

Dose Accuracy


Image Patient

Adaptive Analysis

Delivery System QA




Planning

4D Components

Delivery


4D Images (>1000)

4D Tools & Issues





4D Gamma Index?4D Dose Point?4D Edge Profile?Accuracy?


Which Plan or Phases?

Which Phases to be consider?

Trigger Tomotherapy is possible?

4D-MVCT?

Tracking the delivery

4D Adaptive RT Reconstruction

NO ANSWER AT THE MOMENT...... BUT FEW IDEAS TO USE MVCT


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4DCT AND PATHOLOGY EXAMS (JUST TO COMPLICATE THE PROBLEMS) (LUNG INVESTIGATION – COLLBORATION WITH CNAO)

Anatomy-Pathology exam before formalin

Anatomy-Pathology exam after formalin

1. Compare the tumor shrinking (from formalin)2. Analyze 4DCT studies and define rotational – translation matrix3. Analyze 4DCT studies and define the volume evolution during

breathing acts4. Merge CT and Anatomy-Pathology exam5. Try to confirm PET and MRI (not for lung) contouring6. Working with CNAO Groups to compare Treatments with Protons

and Carbon Ions and Gating Radiation Therapy

… Dynamic IMRT Treatment of the lesions using robotic couch or Tomotherapy....

.... if the 4D or the technology will be available....

Group Coordinator : Prof. Lorenzo Magno

CNAO Work-Group for Lung Carcinoma (NOC)Radiotherapy: Filippo Bertoni : [email protected] Bignardi : [email protected] Luigi Franco Cazzaniga : [email protected] Frezza : [email protected] Salvi. [email protected] Scorsetti :[email protected] ...Medical Physics:Gabriele Guidi: [email protected] Palombarini: [email protected]:Giulio Rossi: [email protected]:Maria Grazia Amorico: A .Ospedaliero-Universitaria di ModenaEnnio Gallo : [email protected] Torricelli: [email protected] Medicine:Bruno Bagni: Università degli Studi di Modena e Reggio EmiliaPneumology:Mario Bavieri: U.O. di Pneumologia , A .Ospedaliero-Universitaria di ModenaEmmanuela Meschiari: U.O. di Pneumologia, A .Ospedaliero-Universitaria di ModenaTorax Surgery:Corrado Lavini [email protected] Morandi: Università degli Studi di Modena e Reggio EmiliaOncology:Fausto Bavieri: U.O. di Oncologia, A .Ospedaliero-Universitaria di ModenaPsychologyAnnamaria Bonardi [email protected]:Roberto D’Amico: Ufficio Trial Dip. di Onc. ed Ematol., A. Ospedaliero-Universitaria di Modena

Work in Progress : Gabriele Guidi – Giulio Rossi

mailto:[email protected]

mailto:[email protected]


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Conclusions

Special Thanks to Elisa & Luciano

1. 4D could be applicable by any center with a 4DCT and a tracking device

2. Long time consuming (imaging, contouring, plan, dose and QA) especially without 4D Tools

3. Many open issues, about dosimetry (Shift and Under-dosage)4. Evident missing at the border of the target (do we need specific

target margin?)5. Target motions has a big influences on the real doses delivered

(Anatomical missing and potential failure of the RT)6. 4D dose reconstruction could help to analyze the results 7. ITV can guaranties a partial margin reduction8. 4D with Tomotherapy: necessary to use ITV or adequate margin

to the target and analyze carefully your clinical objective, before to treat patient

4D work with time.........we need time to investigate the problems......but patience and any help could be important!!

4D

PhysicistDoctors

Will I see a 4D Tomotherapy Treatment?

EMEA 2009 Tomotherapy User Meeting 4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE EFFECTS OF THE TARGET MOTION G.Guidi1, M.Amadori2, E.Cenacchi1, L.Morini1, C.Danielli1, F.Bertoni2

2009 emea 4d tomotherapy

Health & Medicine

4d inverse

tumor movements

population

real doses

4d gamma index

long time

4d edge profile

4d dose point