Advances in Image-guided Brachytherapy · Standard treatment for Cervix Cancer • Standard...
Transcript of Advances in Image-guided Brachytherapy · Standard treatment for Cervix Cancer • Standard...
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Advances in Image-guided Brachytherapy
Hospital Authority Convention 2016
Terry Wong, Physicist
Department of Medical Physics
Pamela Youde Nethersole Eastern Hospital
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What is Brachytherapy?
How we do it in a traditional way?
Introduction
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Radiative source radiation destroy cells
Brachy: short distance Close to target receive much more radiation
What is Brachytherapy
Radiative source
Radiation
Target e.g. cancer cells
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Standard treatment for Cervix Cancer
• Standard treatment for gynecological disease, especially cervix cancer
• Put an applicator into patient’s body through natural cavity
• Load radiative source into applicator (i.e. a path for radiative source)
• Giving radiation dose to the target (cancer cells)
Applicator
Cervix
Vagina
Uterus
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Applicator
Cervix
Vagina
Uterus
Standard treatment for Cervix Cancer
• Load radiative source into applicator (i.e. a path for radiative source)
• Giving radiation dose to the target (cancer cells)
High radiation dose region
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Define a point A
Prescribe dose to point A
Create a pear shape high dose volume
Suppose the target is within this high dose volume
Commonly used method: Manchester point A system
ABS guidelines 2000
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Problems of traditional 2D planning ?
Why we need
Image-guided Brachytherapy (IGBT)?
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From a 2D X-ray image, no contrast of soft tissue
Uncertain the geometry of both target/normal tissue
Lack of information
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Underdose
Small tumor Big tumor
Same dose for all patient, whatever size/shape of tumor
Maybe underdose for more advanced stages/bulky tumors
Because we cannot see the target unique radiation dosage
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Defined point dose for normal tissue dose may not be representative
• The dose at these points may not correlate to the normal tissue complications very well
International protocol
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Can you detect improper applicator placement e.g. uterine perforation?
From 2D? From 3D?
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3D Volumetric images
Moving from 2D planning to 3D planning
Let us solve the problems!
Image-guided Brachytherapy (IGBT)
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Computed Tomography (CT)
Sigmoid
Bowel
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Magnetic Resonance Imaging (MRI) Gold Standard
Bowel
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With volumetric images, you can
See and outline the target and normal tissue
Verify applicator position, detect uterine perforations
Optimize the dose: more dose to target and less dose to normal tissue
Adaptive treatment
Image guided Brachytherapy from 2D to 3D
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GEC ESTRO recommendations and new ICRU guidelines
Target Dose to point A
Dose to volumes
GEC ESTRO I Haie-Meder 2005 GEC ESTRO II Potter 2006
Normal tissue Dose to ICRU points
Dose to volumes
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Interstitial Needles new path for radiation source
Target underdose
Without needle With needle Larger high dose volume
to cover target
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Dose optimization more dose to target and less dose to normal tissue
Standard plan Optimized plan
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Adaptive planning re-contour the normal tissue each fraction
Different shape of normal tissue at different time e.g. Bladder volume
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Pre-treatment virtual planning
Pre-treatment virtual planning
Real treatment
• Predict the dose of real treatment
• Optimize treatment e.g. determine needle position and length
• Help decision making
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Favorable outcome of IGBT overseas experience
Improved survival
Reduced toxicity
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IGBT for cervical cancers since January 2015
1st MRI based planning in Hong Kong
MRI/CT based planning for all cases
1st interstitial needle case in Hong Kong in September 2015
Pre-treatment virtual planning to optimize the treatment
IGBT experience in PYNEH
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Role of Physicists in IGBT Commissioning & Quality Assurance
make sure the intended dose is delivered accurately to the intended location
Commissioning of MR compatible applicator
Independent dose calculation
Confirmation of needle length
Confirmation of needle position
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Role of Physicists in IGBT Treatment Planning
stimulate the dose in patient for the treatment
Image registration
Applicator reconstruction Dose Optimization
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Role of Physicists in IGBT Research and Education
IGBT workshop 2015 at PYNEH
0
5
10
15
0 1 2 3 4 5 6 7
D9
0 (
Gy)
Max Radius (cm)
HRCTV - Dose Relationship (no needles inserted)
Wk 6&7
Target size vs dose coverage
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IGBT: the movement from 2D planning to 3D planning (CT/MRI)
IGBT has the potential that makes brachytherapy more accurate, safe and effective
IGBT has been implemented in PYNEH last year
Summary
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Oncologists
Gynecologists
Radiologists
Anesthesiologists
Nurses
Radiation therapists
Physicists
Team work Collaboration among different disciplines
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Our IGBT team
Thank You!