Image Guided Proton Therapy and Treatment Adaptation

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1 Image Guided Proton Therapy and Treatment Adaptation

2 Cancer in The Netherlands About 1 in 3 people get cancer in some stage of their life new cancer patients per year in 2007 Aging population: new patients expected in 2020, rising by 1% - 2% per year until 2040 About half of all treatments involve a form of radiotherapy About 52% of patients still live 10 years after diagnosis PS: about 30% of all cancer deaths are due to smoking Source: Kanker in Nederland tot 2020 ( 2

3 Holland Proton Therapy Center Reactor Institute Delft Dennis R. Schaart Delft University of Technology

4 R&D Program Three main areas of research 1. Prove clinical value of proton therapy 2. High-precision proton therapy 3. Biology-driven proton therapy

5 Photon radiotherapy Modern radiotherapy linacs allow irradiation from multiple angles using beams with varying shapes and intensity profiles, to maximize the tumor dose while minimizing the dose to healthy tissues. 13

6 The radiotherapy challenge Killing all tumor cells without causing irreparable damage to healthy tissues Different cell types have different radiosensitivity Source: Bernier, Hall & Giaccia, Nature Reviews Cancer 4, (2004) 14

7 Paradigm 1: Fractionation Making use of the difference in repair capability of cancerous and healthy cells Conventional radiotherapy Different cell types have different repair capability 15

8 Paradigm 2: Geometric accuracy Aiming to deliver dose to tumor cells only Intensitymodulated radiotherapy (IMRT) plan Proton therapy plan 16

9 Pencil beam scanning 18

10 Protons: high-precision therapy? Rietzel et al. IJROBP 2005: 1535 Albertini et al. Phys Med Biol 2011: 4399 Engelsman et al. Sem Rad Onc 2013: 88 Slide: M. Engelsman, PTCOG 2013, Essen, Germany 30

11 Organ and tumor motion MRI 4D-CT Examples of inter-fraction (left) and intra-fraction (right) target motion 33

12 Image-guided radiotherapy IR movement tracking In-room CT on rails e - -linac MV cone beam CT kv X-ray position control, fluoroscopy Radiotherapy Department, University Hospital Dresden Courtesy: W. Enghardt kv cone beam CT Radiotherapy J. Distler, Bautzen 36

13 Image-guided particle therapy The state of the art (2014) Orthogonal planar X-ray imaging Things start to improve (2014): CBCT in gantry in-room CT OncoRay Courtesy: W. Enghardt, Oncoray 38

14 Time = 7 weeks 4D Digital Patient 4D Digital Patient Tumor dose Lung dose Esophagus OK Image-guided online-adaptive proton therapy Planning Fraction 1 Fraction X Fraction 31 Fraction 32 Fraction 33 Advanced in-room imaging to update 4D digital patient model Motion tracking Online treatment adaptation to match present 4D digital patient model and updated treatment objectives Real-time image-guided 4D dose delivery and verification PT Motion tracking CT Robot Time = 30 seconds In-vivo QA Real-time dose reconstruction

15 Secondary gamma radiation Images: ISoToPE project, TU Delft (D.R. Schaart) & U Groningen / KVI (P. Dendooven) 43

16 In-situ PET 2-minute PET acquisitions starting right after irradiation P.C. Lopes et al, First in-situ TOF-PET study using DPCs for proton range verification, PMB 61, , 2016

17 Prompt gamma-ray imaging Dr. Eelco Lens (TU Delft), ADAPTNOW project 48

18 How to use prompt gamma s clinically? Monte Carlo simulations of realistic patient cases Patient # Plan planned Planning CT Planned dose MC Planning CT Repeat CT 1 Repeat CT 2 Repeat CT # Simulated dose Dr. Eelco Lens (TU Delft), ADAPTNOW project 51

19 Results correlations dose vs. PG V 95% PTV high vs. median ΔX 50 Varying correlation strength Varying linear relations => it s a start! X 50 Dr. Eelco Lens (TU Delft), ADAPTNOW project 53

20 Soft robotics for positioning Kinematic Pillow: Precise and adaptable yet comfortable patient positioning Current radiation therapy head mask Artist impression of envisioned kinematic pillow head support system. From: Just herder et al (TU Delft)

21 Importance of Treatment Planning Conforming the physical dose spatial distribution. Handling anatomy changes, quantifying uncertainties. Robust optimization for proton treatments [2]. Underdosage probability in a non-robust plan [1] From: Zoltan Perko 76

22 Getting it together

23 Holland Proton Therapy Centre Research-driven proton therapy Implementation Patients Results Needs Clinically-driven research & development

24 Thank You

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