Frank Lohr SBRT Consortium London Lohr

DIBH for Motion Management
Frank Lohr, M.D.
University Medical Center Mannheim
Disclosure
Research and Training Agreement, Expert
Testimony and Travel Grants with Elekta/IBA/C-Rad
Board Member of C-Rad
ESTRO IMRT Course May 2013
Mannheim
Mannheim
ESTRO IMRT Course May 2013
ELEKTA MOSAIQ Vers. 2.50
LINAC 1 Elekta Versa HD
Philips Brilliance Big Bore
CT-Simulation, Tumor L.O.C.
X 6,10,18; e, Agility MLC
EPID, cone beam CT, FFF,
Clarity, Intergrity 3.1 (9/2011)
Philips Eleva
LINAC 2 Elekta Versa HD
X 6,10,18; e, Agility MLC
EPID, cone beam CT, FFF,
Clarity, Intergrity 3.1 (9/2012)
PCR System
Elekta ABAS
LINAC 3 Elekta Synergy
Atlas based autosegmentation
X 6; e, MLC,EPID,cone beam
Integrity 1.1, (03/2004)
LINAC 4 Elekta Synergy
5 x Elekta Monaco 3.3
X 6; e, MLC,EPID, cone beam,
Integrity 1.1, (05/2010)
Monte-Carlo Systems
Gammknife
Perfexion 2013
MOSAIQ
6 x Nucletron
Masterplan vers. 4.2
Connection to unit 2
Distance 3 km
100 clients
Intraaoperative unit
Zeiss Intrabeam, 50 KV
Connection to unit 1
Distance 30 km
Seed application
Elekta/Nucletron FIRST
LINAC 6 Elekta Synergy
LINAC 5 Elekta Synergy
X 6; e, MLC, EPID
X 6; e, MLC, EPID
ESTRO IMRT Course May 2013
Relative Plan Distribution
VMAT/dMLC
FFF
Monaco treatment plans :
2012: 1184 Monaco plans (50%)
2013: 1604 Monaco plans (68%)
2014: 442 Monaco IMRT plans (78%)
75 Monaco 3D plans (13%)
Average Slot time including SRS,
ESTRO IMRT Course May 2013
SBRT and TBI: 15 min
Positioning Errors
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CTV
PTV
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PTVIG
How to minimize
PTVIG
ESTRO IMRT Course May 2013
Interfractional Error
Intrafractional Error
ESTRO IMRT Course May 2013
Interfractional Error
Systematic Error
Random Error
Intrafractional Error
PTVIG
ESTRO IMRT Course May 2013
Interfractional Error
Systematic Error
Random Error
Intrafractional Error
PTVIG
ESTRO IMRT Course May 2013
Interfractional Error
Systematic Error
Random Error
Intrafractional Error
PTVIG
ESTRO IMRT Course May 2013
Interfractional Error
Systematic Error
Random Error
Intrafractional Error
PTVIG
ESTRO IMRT Course May 2013
Erhöhung der Präzision der Dosisapplikation
Dosis wird wie geplant appliziert. Korrektur von minimalen Fehlern – Vermeidung von
groben Fehlbestrahlungen
A. Tägliche Positionierung
ohne IGRT. Große
systematische Fehler
(10mm) und große
random Fehler
B. Off-line IGRT.
Kleine systematische
Fehler, aber große
random Fehler
ESTRO IMRT
2013
Bujold
etCourse
al.,May2012.
C. Tägliche online IGRT.
Minimale systematische
oder random Fehler
ESTRO IMRT Course May 2013
Now comes the strange part…..
„Local failure rates at 18 months were
25.1% vs 34.3% for SD and HD patients,
respectively(p=0.03). Local-regional and distant
failures at 18 months were 35.3% vs 44%(p=0.04)
and 42.4% vs 47.8%(p=0.16) for SD and HD arms,
respectively. Factors predictive of less favorable OS
on multivariate analysis were higher radiation dose,
higher esophagitis/dysphagia grade, greater gross
tumor volume, and heart volume >5 Gy“
Bradley et al., ASCO, 2013
ESTRO IMRT Course May 2013
Target Delineation
Bradley, 2014
http://thoracicsymposium.org/MeetingProgram/documents/GSIXBradley.pdf
ESTRO IMRT Course May 2013
Methods of Motion Management
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Tracking
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4D-CBCT
Sweeney
et al.,
Radiation
Oncol,
2012
ESTRO IMRT Course May 2013
MotionComparison
compensation
techniques
of couch
and
MLC tracking
4D techniques
Heidelberg:
Siemens 160 MLC
Würzburg:
HexaPOD Evo
Elekta Meeting Barcelona 2012
21May 2013
ESTRO IMRT Course
MotionComparison
compensation
techniques
of couch
and MLC tracking:
Geometrical accuracy in lung cancer
MLC
HexaPOD
Elekta Meeting Barcelona 2012
22May 2013
ESTRO IMRT Course
Deep Inspiration Breathhold Gating
ESTRO IMRT Course May 2013
Motion of Lung Tumors
ESTRO IMRT Course May 2013
Motion of Lung Tumors
Tumors attached to bony structures are colored red
lower-lobe tumors are colored light blue.
Shirato et al, 2004
Seppenwoolde et al, 2002
ESTRO IMRT Course May 2013
Why DIBH-Gating and not free-breathing inspiration or
endexpiratory Gating?
Favorable OAR exposure
but inefficient and difficult
to achieve sufficient
spatial and linac precision
Efficient and precise but
unfavorable OAR
exposure
ESTRO IMRT Course May 2013
Why DIBH-Gating and not free-breathing inspiration or
endexpiratory Gating?
Efficient, precise and
favorable OAR exposure.
Patient has to be able to
perform DIBH (~80%)
ESTRO IMRT Course May 2013
Possible (partial) remedy: IMRT/VMAT in computer-controlled deep-inspiration breath hold
CC-controlled DIB, ART-Sequence
Midventilation CT
5.12.2011
27.12.2011
1.12.2011
10.01.2012
ESTRO IMRT Course May 2013
DIBH
Marchand et al.,
SUON 2012
ESTRO IMRT Course May 2013
Apnoe-Diving
Apnoe Period - 11 Minuten
Distance Diving – without fins 225m
Depth Divin – without fins 101 m
Spiegel.de
ESTRO IMRT Course May 2013
Problem
Lungenkrebspatienten: Atemanhalt maximal ~15-20s
Bildgebung vor der Bestrahlung mit CBCT: 2 Minuten
Bestrahlungsdauer für eine 12Gy-Fraction (bis 2013):
25-30 min, Bildgebung und Bestrahlung in repetitivem
Atemanhalt
Lösung
hohe Dosisrate mit FFF (flattening filter free) Delivery
Agility (schneller MLC)
schnelle Bildgebung in Atemanhalt
ESTRO IMRT Course May 2013
Durchschnitts-Erwachsener kann den Atem etwa 22 sec anhalten... Aber
meist nicht bis zur Bewusstlosigkeit…:
Mamma-Ca Patienten :
-Übung
-Erhöhung O2 (60%)
-Hypokapnie
-Max. Atemanhalt im RT Raum 6
Minuten...
ESTRO IMRT Course May 2013
Schneller und einfacher Arbeitsablauf – Lungen/Leber
SBRT
Flattening-filter-free FFF 10 MV Versa HD
eine 360°VMAT Rotation
ABC R3.0, DIBH
Automatisiertes gating (Response)
CBCT, EPID
Behandlungszeit: T= 8 min
ESTRO IMRT Course May 2013
Breathhold workflow
Expanded time slot planning CT
for patient training purposes by 10 min.
Breathing
command
CT
Examination room
Image
aquisition
CT
Operater room
Treatment
Treatment
planning
ESTRO IMRT Course May 2013
LINAC
Operater room
LINAC
Treatment room
SABR (Stereotactic Ablative Radiotherapy) :
Can be applied in a standard treatment slot
Flattening-filter-free FFF 10 MV Versa HD
Monaco 8 field dMLC or one 360°VMAT arc
Active breathing coordinator ABC 3
image-guidance XVI, EPID
Transversal and
coronal PET-CT
images of the patient
First fraction setup time incl. ABC/ CBCT and
EPID: T= 30 min (incl. documentation)
treatment time: T= 8 min (8 beams, 2.3k MU)
J. Boda Hegemann
et al.
2013
Oncol.
ESTRO IMRT
Course
May Radiother.
2013
Filter setup Mannheim
flat
FFF
photons - potential in (MV)
6
√
√
10
√
√
18
√
Ø
electrons - energy in (MeV)
low: 4, 6, 8
√
√
mid: 10, 12, 15
√
√
high: 18, 20, 22
Ø
Ø
ESTRO IMRT Course May 2013
Response gated lung treatments
2 Gy per fraction
SABR 5×12 Gy
Gamma 3%/3mm [%]
98,22
96,74
96,94
99,57
99,02
95,03
100
97,45
99,84
98,75
98,16
Energy
10FFF
6FFF
10FFF
6FFF
10FFF
10FFF
10FFF
10FFF
10FFF
10FFF
Modality
MU
VMAT
2216,21
VMAT
2322,2
VMAT
4138,64
VMAT
2092,4
DMLC
2365,5
DMLC
2300,1
DMLC
1861
DMLC
2259,8
DMLC
2335,6
VMAT
3803,34
2569,48
Gamma 3%/3mm [%]
99,72
99
97,58
99,2
95,2
96,69
95,19
99,99
100,00
99,92
98,25
Energy
10MV
10MV
10MV
6MV
6MV
6MV
6MV
6MV
6MV
6MV
Modality
VMAT
VMAT
VMAT
VMAT
VMAT
VMAT
VMAT
VMAT
VMAT
VMAT
MU
702,3
974,4
571,1
515,4
910,2
1184
908,1
559,3
417,6
416,5
715,89
For both lung SBRT in FFF-technique and normofractionated IMRT with conventional
beam delivery treatments, automatically gated (ABC and Response) DIBH (deep
inspiration breath hold) is dosimetrically robust.
A. Simeonova and A. Jahnke, et al
ESTRO IMRT Course May 2013
Boda-Heggemann et al., Radiother Oncol, 2011
CBCT
(ABC Breath hold)
Planning CT
(ABC breathhold)
CBCT
Free breathing
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Imaging in DIBH
1. Cone-beam CT
Planungs CT
CBCT
60% Atemanhalt
40% freies Atmen
CBCT
100% Atemanhalt
(Response
Schnittstelle)
ESTRO IMRT Course May 2013
CBCT (XVI) with ABC
in partial breath-hold vs. total breath-hold
deep inspiration
60 % breath-hold vs. 100 %
gradient image
Boda-Heggemann, Jahnke et al.,
ASTRO/DEGRO 2014
J. Boda-Heggemann et al.
ESTRO IMRT Course May 2013
DIBH: Target stability over 12 Fractions
GTV Movement
Qualitatively
GTV Movement
Quantitatively
Consequences for
Target Coverage
ESTRO IMRT Course May 2013
ESTRO IMRT Course May 2013
DEGRO AG Stereotaxie: gepoolte Analyse
691 Patienten
1y-LC rate 90%
2y-LC rate 80%
Sterzing/Guckenberger et al, DEGRO 2014
ESTRO IMRT Course May 2013
ESTRO IMRT Course May 2013
Spiral Breathhold
Planning CT
Breathhold-Only
CBCT
ESTRO IMRT Course May 2013
ESTRO IMRT Course May 2013
Herfarth Typ I.
Portal-venöse
phase
Herfarth Typ III.
Portal-venöse
phase
Herfarth Typ II. Portal-venöse
phase hypodens, Spätphase
hyperdens
ESTRO
IMRT Course May 2013
MR-morphologische Veränderungen nach SBRT
Follow-UP: QA.... and possibility for dose correlation with functional imaging:
radiation tolerance data based on functional imaging
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Breathhold Surveillance
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Surface Detection
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Catalyst
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Surface-based Surveillance
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ESTRO IMRT Course May 2013
Correlation of Catalyst Gating Signal and Diapraghm Position
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Ultrasound – Work in Progress
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ESTRO IMRT Course May 2013
ESTRO IMRT Course May 2013
Bildgebung in Atemanhalt – Ultraschall
Clarity Autoscan - liver probe and setup
ESTRO IMRT Course May 2013
Ansatz kV+MV-Rekonstruktion
kV
MV
http://www.elekta.com/healthcare_international_beaumont_work_results_breakthrough.php
ESTRO IMRT Course May 2013
Arns, Wertz et al
ESTRO IMRT Course May 2013
Cylinder kVMV
A. Arns, PD Dr.ESTRO
H. IMRT
Wertz,
M.2013
Blessing
Course May
ESTRO IMRT Course May 2013
1- MRI guided Radiation Therapy
MR scanner /60Co
ESTRO IMRT Course May 2013
3- MR LINAC
Lagendijka JW et al. Oncology, 2008
Raaymakers BW et al, Phys. Med. Biol. 2009
Crijns SPM et al, Phys. Med. Biol. 2012
ESTRO IMRT Course May 2013