Stereotaxy. Outlines. Establishing SBRT Program: Physics & Dosimetry. SBRT - Simulation. Body Localizer. Sim. Sim. Sim. Stereotaxy?

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1 Establishing SBRT Program: Physics & Dosimetry Lu Wang, Ph.D. Radiation Oncology Department Fox Chase Cancer Center Outlines Illustrate the difference between SBRT vs. CRT Introduce the major procedures in SBRT: Simulation while assessing target motion; Target definition: how to account for motion; planning consideration; delivery with imaging guidance. Present physics and dosimetry issues involved. SBRT Sim Target Definition CRT Sim Target Definition SBRT - Simulation Sim Planning Planning Stereotaxy? Patient Immobilization? Patient Motion Assessment? Delivery Delivery Stereotaxy Body Localizer Tumor Localizer rods Body frame Origin (,,) Body pillow (,) (,) Isocenter Indexing laths Patient Stereotaxy refers to a 3D superposition of a fixed coordinate system upon a given organ. clamp Carbon fiber base board SBL provides a rigid reference for patient setup and re-alignment, as well as assists image fusion. 1

2 Stereotaxy in Extracranial Sites 3D Images Provide Stereotaxy Y Tumor Localizer rods (,) Origin (,,) (,) Bony landmarks (x, y, z) Isocenter X Z SBRT must be based on 3D images! Conventional vs SBRT Patient Immobilization * Slide courtesy of Brian Kavanagh / University of Colorado SBRT simulation begins with patient-specific mold making and immobilization of patient. Motion Assessment 4DCT Simulation SBRT requires a determination of patient-specific internal target volume (ITV) What imaging procedures to use in order to determine the ITV? 2

3 Multiphase CT Scans & Image Fusion Scans taken at: Inspiration breath hold Expiration breath hold Normal breathing Frame registration helps to contrast the tumor motion Establish stereotaxy for target localization Composite Target or ITV Motion Study with MRI Cine fiducial Three targets from normal breathing, inspiration and expiration breath hold scans. Due to motion artifact, the target on the normal breathing appears to have two separate targets (green). tumor P A tumor Motion (mm) Motion Comparison Motion (mm) SI direction Patient # CTs vs. MRI AP direction MRI cine 3 CT scans Patient # Motion (mm) MRI cine 3 CT scans LAT direction Patient # MRI cine 3 CT scans SBRT Target Definition Patient-specific ITV is defined? PTV Other uncertainties have been determined? 3

4 ITV Definition Other Uncertainties 4D MIP Approach: 3 Multiphase CT Approach: Inspiration Normal breathing expiration Whether using 3D imaging guidance? If yes, how much uncertainty is associated with the imaging system? Can setup error completely be corrected by imaging guidance? If not, what is the residual error (image resolutions,..etc)? Patient specific ITV Comparison of Target Definitions Volume Comparison ITV Parameter Planning CT scan GTV or ITV 3D standard Free-breathing slice- based Standard GTV 3 Multiphase CT Max. inspiration and expiration breath holding +free-breathing CTs GTV_free U GTV_insp U GTV_exp 4D Union 4D CT (or MIP) GTV1 U GTV2 U U GTVn ITV Volume Comparison ITV_4D ITV_3CT GTV_conv CTV PTV GTV+. cm CTV+. (cm) setup + population based tumor motion ITV+. cm CTV+.3-.cm.cm (setup) ITV+. (or.3) cm CTV cm (setup) 1 1 Range of tumor motion GTV_insp GTV_norm GTV_free GTV_exp GTV Patient Volume Comparison PTV PTV Comparison PTV_4D PTV_3CT PTV_conv SBRT Planning Planning 4 3 What beam margin? Beam arrangement and energy? Target conformality? Patient What dose fall-off? How much dose inhomogeneity? Co-planar or non-coplanar PITV index and % IDL More underline issues maybe exist: such as commissioning for small fields 4

5 Typical Margins Used Dose Fall-Off Various margins were reported: from 1. cm It depends on the dose inhomogeneity desired. It also depends on the machine to be used for treatment planning such as Cyberknige - may use multiple isocenters thus, the dose inhomogeneity is high. 6% SBRT 9% CRT MC Investigation of Block Margin Non-coplanar Beam Arrangement V of two lungs (%) 2 3 Density_lung =.1 g/cm No suggestion for block margin, 3 Density_lung =.2 g/cm 3 Density_lung =. g/cm 1 1 b a c Beam margin (mm) Coplanar Beam Arrangement Energy Effect in Patient 6 MV - MC 1 MV- MC Wang et al J. Appl. Clinc Med. Phys. (2)

6 Energy Effect in Patient Wang et al J. Appl. Clinc Med. Phys. (2) Target Conformality Different protocol has different specifications. E.g. RTOG 91 Requires: PITV is close to unit as much as possible (1.2 1.) % line also should follow the shape of the target the distance from the prescribed IDL to the % IDL < 2. cm The prescription isodose surface must be 6% and < 9% of the maximum dose (normalized to the maximum dose point). High dose spillage requirements: - the cumulative volume of all tissue outside the PTV receiving a dose >1% of the prescription dose should be no more than 1% of the PTV volume. SBRT Delivery Delivery Linear Accelerators with features especially suitable for SBRT Delivery System? Adopted system? Specialized SRT: Novalis, Cyberknife, Trilogy? Imaging Guidance? Bony alignment or soft tissue alignment? Gating or Tracking? Is surrogate moving in phase of the target? On Board Imaging Cone Beam Cone Beam CT Guidance after bony alignment 6

7 Cone Beam CT Guidance after soft tissue alignment Image Guidance using CT-on-Rails PRIMART Siemens PRIMARTOM in a treatment room. Setup Image Guidance using CT-on-Rails Zero the table coordinate setup based on a stereotactic box to establish the rigid relationship with the machine reference. CT Gantry Retracts Prior to 3-D Target Localization with a SOMATOM CT Gantry Moves During Slice Acquisition Carbon Fiber Tabletop Rails PRIMART ZXT Table SOMATOM Sliding Gantry PRIMART ZXT SOMATOM Sliding Gantry Daily Target Localization: Bony Landmarks Shifts Patient Relocalization for Coordinates from SIM CT New coordinates from CT CT Gantry Retracts Prior to Origin (,,) Tumor Localizer rods (, (,) ) Origin (,,z) Tumor Localizer rods (, ) Bony landmarks (x, y, z) Isocenter Bony landmark (x, y, z ) X = X X, Y=Y Y, Z = Z -Z PRIMART ZXT Shift the table if necessary SOMATOM Sliding Gantry 7

8 Physics & Dosimetry Issues Small field dosimetry - beam commissioning for small fields (output factor, profile etc.) Quality assurance of imaging guidance system known the accuracy and limitations Using IMRT vs. conformal approach is there any benefit in using IMRT and when to use it? Summary: SBRT Requirements Higher confidence in tumor targeting and appropriate accounting of internal organ movement. Reliable mechanisms for generating focused, sharply delineated dose distributions Reliable accurate patient positioning accounting for target motion related to time dependent organ movement SUMMARY: SBRT Physics and Technology CT simulation: Need assess tumor motion Immobilization: Minimize motion, breathing effects Planning: Small field dosimetry considerations Repositioning: High precision patient set-up. Relocalization: Identify tumor location in the treatment field: Thank you! * MV/ kv x-ray, x implanted markers and/or set-up fiducials * Motion tracking and gating systems * Real-time tumor tracking systems with implanted markers delivery techniques * Adapted conventional systems * Specialized SRT: Novalis, CyberKnife,, Trilogy 8

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