D205 Simpósio Varian - True Beam initial experience in Humanitas
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Transcript of D205 Simpósio Varian - True Beam initial experience in Humanitas
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FILIPPO ALONGI M.D.Istitutostituto Clinicolinico HumanitasumanitasRadiotherapyadiotherapy andnd Radiosurgeryadiosurgery Deptept..
Introduction and overview ofTRUE BEAM
initial experience in Humanitas
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Humanitasumanitas cancerancer centerenter
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Radiotherapyadiotherapy Departmentepartment
Technologies:4 linear accelerators (Varian) OBI and Cone Beam CT1CT simulator (Philips, Big Bore, 16 slice)5 Treatment planning systems (4 Eclipse+1Ergo)4D system for gated respiratory motionTools for radiosurgery and SBRT
TRUEBEAM
CT SIMULATOR
DHX- OBI, CBCT
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Lung
Gyn
Brain
Breast
Metastasis
GIGU
Other
Sarcomas
H & N
Radiotherapy@Humanitas in 2010adiotherapy@Humanitas in 2010
Patients treated in the last year in RT
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PrecisionAccuracyEfficiency
Whathat iss ourur strategytrategy ?
MultimodalityimagesCT/PET/MRI
IMRT andVMAT Radiosurgeryand SBRT
IGRT andadaptive RT
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Robotic controle of Positioning Unit (PU) and IsoCal
Three roboticarms
Responsible forimaging anddetector units
kV-Source
kV-Source
Arm
MV-DetectorArm
kV-DetectorArm
kV-DetectorHand holder
MV-DetectorHand holder
Gantry Side
Creates an ideal image guidancemachine by alignment of the imagingsystem to isocenter
True isocenter is a single pointwhich coincides with the kV/MV
rotation centers and where the centerof the imagers project
Specification for imager to treatmentisocenter is 0.5mm
Treatment iso
MV imaging iso
kV imaging iso
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RapidArc IMRT with FFF (10X: 24 Gy/min) Automated Simultaneous, synchronized control points
for all axes(MLC, MV beam, gantry, table, collimator, 3rd party, kVbeam)
Collimator and couch rotation during beam-on
Jaw tracking for IMRT and RapidArc
Table tracking, MLC tracking
Connected Multiple isocenter plans (e.g., SRS, longfields, imaging fields)
Preventive Collision detection during machine motion(safety)
Isocal: automatic alignement of imaging and Txisocentres
Not all features available at first releaseCourtesy of L. Cozzi
TRUE BEAM
Some appealing features - beam
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D1 D2D1 = D2
Flattering filter vs FF free
D1pre >> D2pre
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TRUE BEAM: Beams profiles6FFF 6X
10X10FFF
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Combined (kV-MV) single and continuous
Synchronous acquisition using both
modalities
Combined (kV during MV) single and
continuous
Combined kV-MV single and continuous
synchronised with gating
kV 4D CBCT
Not all features available at first release
TRUE BEAMSome appealing features - imaging
Courtesy of L. Cozzi
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TrueBeam Imaging Examples
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Not all features available at first release
Observe motions before AND duringtreatment
Fluoroscopy-based respiratory gatedRapidArc
Fluoroscopy based motion detectionfor anatomical target tracking
TRUE BEAMSome appealing features - imaging
Courtesy of L. Cozzi
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TrueBeam Imaging Examples
Courtesy of Zurig
Fluoro_during_RA_LUNG.wmv
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TRUE BEAMRUE BEAM clincicallincical potentialotential advantagesdvantages
GREATER PRECISIONREATER PRECISIONin:
Delivery high doses
Image guidance
Higher doses to thetumor(improves local control)
Increased possibility touse non conventionalfractionation (decreases
toxicity with SBRT)
Flatteringlattering Filterilter Freeree(FFF)FFF)New clincal application
New Radiobiology
implications
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TrueBeam@Humanitas
Installation 10/7-15/8/2010
Acceptance tests 16/8-20/8/2010
Commissioning 23/8-19/9/2010
1st patient 20/9/2010
Total patients 123 @31/12/10
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TRUE BEAM initial clinical experience
123 patients(68 with FFF) 98/123 pts completed the treatment.
Brain and CNS= 8ptsH&N= 4pts
Lung= 73pts(49pts FFF)20 pts >4 fr.(20Gy-30)53 pts 4 fr.(32-48Gy)
Abdomen =25pts-Liver 13pts (9FFF) (75 Gy/3fr)-Ln 7pts (45 Gy/6 fr.) (3FFF)-Other 5pts (pancreas=3, adrenal glands=2)Other sites =13pts (7FFF)
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PrecisionAccuracySelectivityEfficiency
Greater precision (isocentre
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TRUE BEAM Clinical applications
First patients with 10FFFirst patients with 10FFF
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TRUE BEAM initial clinical experiencewith FFF beam
49 SBRT for lung lesions:Doses: 32-48 Gy in 4 fract.Toxicity:1 case of G1 esophagitis
9 SBRT liver lesions:Doses: 75 Gy in 3 fract.Toxicity:1 case of G1 nausea/vomit
Acute toxicities: no G28 FFF treatments
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TRUE BEAM initial clinical experiencewith FFF beam
7 other sites in the body:Doses: various.Toxicity: none
3 SBRT for abdominal lymph nodes:Doses: 45 Gy in 6 fract.Toxicity: none
Acute toxicities: no G28 FFF treatments
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Truerue Beameam potentialotential applicationspplications:SBRT LUNGBRT LUNG
RESULTS
The survival rate for SBRT is potentially
comparable to that for surgery.
2010
Flattering Filter Free beams:Higher doses delivered moreprecisiously
TRUE BEAM
Vassiliev ON et al. Stereotacticradiotherapy for lung cancer using aflattening filter free Clinac.J Appl Clin MedPhys. 2009 Jan 27;10(1):2880.
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SBRT in lung: 12Gyx4;10FFF;DR 2400.
Heart: mean dose = 2.6Gy
Lung: mean dose = 7.5
Gy (left) 5.7 Gy (right)Spinal Cord: max dose =13.0 Gy
4D CT
2 isocentres
2 full arcs
Jaws tracking
MU: 3014+3606
BOT:75+91s
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Heart: mean dose = 3 Gy
Lung: mean dose = 2 Gy
(left) 8 Gy (right)
V5Gy = 40%
V20Gy = 8%
Esophagus: V33Gy ~ 0%
1 isocentres
2 partial arcs
Jaws tracking
MU: 2212
BOT: 2x 32 s
SBRT in lung: 6Gyx6;10FFF;DR 2400.
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ACCEPTED 2011
SBRT IN ABDOMINAL TARGETS
Stereotactic body radiation therapy for abdominal targets using volumetric intensitytereotactic body radiation therapy for abdominal targets using volumetric intensitymodulated arc therapy with RapidArc: feasibility and clinical preliminary resultsodulated arc therapy with RapidArc: feasibility and clinical preliminary resultsMarta Scorsetti,1 Mario Bignardi M,1 Filippo Alongi,1 Antonella Fogliata c,2 Pietro Mancosu 1 Piera
Navarria,1 Simona Castiglioni,1 Sara Pentimalli,1 Angelo Tozzi MD,1 Luca Cozzi,2
1 IRCCS Istituto Clinico Humanitas, Rozzano (Milano), Italy2 Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
SBRT in abdominal TARGETSBRT in abdominal TARGETS
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Truerue Beameam potentialotential applicationspplications:SBRT LIVERBRT LIVER
75 Gy in 3 fractions
TRUE BEAM
Liver metastasis treatment in ICHRadioablation
RAPID ARC
Better precision more ablative doses?
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Humanitas LIVER SBRT protocolumanitas LIVER SBRT protocol
Organ at risk Dose constraints(for 3 fractions) Other conditions
Normal liver(total liver - CTV) > 700 cc at < 15 Gy Volume > 1000 cc
Spinal cord < 18 Gy -
Kidneys V15 Gy < 35%Heart < 30 Gy Esclusion criteriaCTV at < 8mm
Stomach, duodenum, smallbowel, principal biliar ducts < 21 Gy(Dmax) Esclusion criteriaCTV at < 8 mm
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Humanitasumanitas LIVER SBRTIVER SBRT protocolrotocol
Dose/fraction Numberfractions Median dose
Standard dose 25Gy 3 75 Gy
Dose reduction 10% 22.5 Gy 3 67.5 Gy
Dose reduction 20% 20. 63 Gy 3 61.89 Gy
Dose reduction 30% 18.75 Gy 3 56.25 Gy
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Humanitasumanitas LIVER SBRTIVER SBRT protocolrotocol
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CB_CT
Day I CB_CT
Day III
CT simulation & CB CTT simulation & CB CT
Basal
ArterialphaseVenous
phase
Late Venous
phase
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Humanitasumanitas protocolrotocol
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SBRT with Rapid ArcBRT with Rapid Arc
Simulation CT
CT pos
CT pre
F, 62y, liver met, 75 Gy/3 fr
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FFF vs FF for liver metastases
13 liver lesion patients 25 Gy for 3 fractions optimized on PTV Variable PTV volumes (20 to 300cc) 4 plans/patient: FFF with collimator at 10 and 45
FF with collimator at 10 and 45
Parameters:
PTV Conformity Index
HT mean dose
CTV mean dose
%95
%95
_
_
VPTV
VBodyCI
FFFbetter sparing on HT
FF
For target best solutiondepends on lesionvolume
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FF coll 45
FFF coll 45
FFF vs FF for liver metastases
Reggiori ESTRO 2011 submitted
20-70cc 71-110cc 111-200cc
20-70cc 71-110cc 111-200cc
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1 isocentre, 1 arc
Jaw tracking
Spinal cord max dose = 17.3 GyRight kidney mean dose = 3.9 Gy
Liver mean dose = 15.7 Gy
Stomach mean dose = 19.3 Gy
SBRT liver with TB: 25Gy x 3; 6FFF; DR 1200.
MU: 5642
BOT: 137 s
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1 isocentre, 3 arcs
Jaw trackingPTV1&PTV2: V95%=99.5%
Spinal cord: Max dose=17.3 Gy
Stomach: Max=21.0Gy, Mean=9.5 Gy
Liver: Mean=15.5 Gy, D15Gyfree=712cc
SBRT liver: 25Gy x 3; 10FFF; DR 2400.
MU:3216+3527+563
BOT: 80+82+14s
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Prospective Phase II multicentric study of SBRTfor liver metastases
From December 2009 to December 201024 patients (21 with Rapid arc, 3 FFF with TBFFF with TB)
16 total dose, 8 reduction of dose to 30%
Only 1 acute toxicity gr2 (vomiting)
Increase ofGT in 5 patients without altered hepatic function
Median FU: 8 months
7 CR - 4 PR - 5 SD - 5 PD (local, out of treatment volume)
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SBRT abdominal lymph nodesBRT abdominal lymph nodesAbdomen:LN mts
2009
2010
DOSE: 45 Gy/ 6 Fr
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1 isoc, 1 arcsJaws tracking
MU: 1065
BOT: 66 s
Rectum mean dose = 9.9 Gy
Femoral heads mean dose = 1.6 Gy
SBRT: 3.5Gyx10;6FFF;DR 1200.
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1 isoc, 1 arcs
Jaws tracking
MU: 1697
BOT: 60 s
Kidneys mean dose = 1.5 Gy
Spine: max dose = 7.5 Gy
SBRT: 7.5Gyx6;10FFF;DR 2400.
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Other special techniques: Total Marrow Irradiation (TMI) Partial Breast Irradiation
Vertebral re-treatments
Cervico-facial district re-treatments
Whole brain irradiation withintegrated boost on cerebral lesions.
Intensity Modulated Radio Therapy(IMRT) and Image Guidance (IGRT):
Locally advanced lung tumour Pleuric mesothelioma Breast irradiation with Simultaneous
Integrated Boost
Cervico-facial district neoplasiae
Esophagus tumours
Pre operatory rectum cancer
Radical and post-operatory prostatecancer
Vertebral metastasis with spinal cordsaving
Otherther Clinicallinical Applicationspplications
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Nasopharynx re-treatment: 6Gy x 5; 10FFF; DR 2400.
MRI
PET
1 iso, 2 arcs
Jawstracking
MU:925+1105
BOT:60+60s
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Nasopharynx re-treatment: clinicalresponse
Pre-RT
Pre-RT After 45days
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1 isoc, 1 arcs, 4 lesions
Jaws tracking
MU: 1523
BOT: 68.4 s
Optical nerves max dose = 10.5 Gy
Brainstem mean dose = 7.5 Gy
SBRT brain: 6Gy x 4; 6FFF; DR 1200.
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A second protocol is in assessment: TMLI in lymphomaFirst patient treated on October 26:
TMLI for Hodgkin lymphoma stage IVB.
Marrow stem cell transplant from his son.
Low intensity conditioning + ciclophosphamide
PTV TML: 2.2 Gy. PTV boost: 2 GyDelivery on TrueBeam with 10 arcs and 5 isocentres.
10 MV photons
Lower legs with AP-PA fields.
Both plans are summed in Eclipse,
AP-PA used as base dose plan for RA
Pre-treatment QA done with MatriXX and PortalImaging
Image guidance: CBCT at every isocentre
TotalTotal MarrowMarrow LymphLymph--nodenode IrradiationIrradiation -- 11
First patient treated
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Good dose homogeneityand good QA results
PTV: V2Gy=99.8%
HT: mean dose=1.2Gy
Total Marrow LymphTotal Marrow Lymph--node Irradiationnode Irradiation -- 33
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Phase II trial
Total marrow irradiation (TMI) using VMAT-Rapid Arc as part ofpreparative regimen for allogeneic stem cell transplantation and
autologous stem cell transplantation
Primary objective and end-point:
Response Rate: CR and PR
100-d treatment related mortality
Secondary objective and end point: OS,
PFS, response rate, incidence of severe
toxicities (grade III/IV)
Pre-clinical phase:
In silico evaluation of planning
techniques and delivery accuracy
Age 18-65. 2x36 patients
Allogenic: Acute Myeloid Leukemia
Autologous: Multiple Myeloma relapsed afterautologous stem cell transplantation
Allogenic regimen: 12 Gy TMI + Fludarabine,
Busilvex, ATG
Autologous regimen: 12 Gy TMI + Melphalan
100mg/m2
Total Marrow Irradiation with TrueBeamTotal Marrow Irradiation with TrueBeam
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TRUE BEAM: CONCLUSIONTRUE BEAM: CONCLUSION
IMPROVE
CLINICALOUTCOME
CONE BEAM
SBRT with FFF
delivery
RAPID ARC
VMAT delivery
PATIENT BASED APPROACHPATIENT BASED APPROACH
FLUOROSCOPY
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TRUE BEAM TEAM:TRUE BEAM TEAM: ThanksThanks!!!!!!