Fiducial-Free Lung Tracking and Treatment with the CyberKnife System: A Non-Invasive Approach
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1 Fiducial-Free Lung Tracking and Treatment with the CyberKnife System: A Non-Invasive Approach Jesse McKay, MS, DABR Erlanger Health System Chattanooga, TN JASTRO 2014, Yokohama Japan
2 Disclosure I have received an honorarium for preparing and delivering this presentation. I have no other relevant financial relationships to disclose. Fiducial-Free Lung SBRT with CyberKnife
3 Overview CyberKnife utilization at Erlanger Lung Optimized Treatment (LOT) basics Erlanger workflow Sim Planning Treatment Outcomes Fiducial-Free Lung SBRT with CyberKnife
4 Erlanger Beginnings First center to purchase LOT Bundled with CK VSI system 1 st patient in April 2011 LOT installed in August 2011 Fiducial-Free Lung SBRT with CyberKnife
5 Erlanger Beginnings Why fiducial free? 5-10% risk for Pneumothorax Bleeding, infection, etc. Complicated tracking Migration, spacing, etc. Additional cost Delay of treatment Fiducial-Free Lung SBRT with CyberKnife
6 Erlanger Beginnings Why fiducial free? 5-10% risk for Pneumothorax Bleeding, infection, etc. Complicated tracking Migration, spacing, etc. Additional cost Delay of treatment Fiducial-Free Lung SBRT with CyberKnife
7 Tracking Stats Treated over 350 LOT cases Xsight Lung Xsight Spine LOT 1-view A 60% of total patients are lung, nearly all fiducial-free 6D Skull (SRS) Fiducial-Free Lung SBRT with CyberKnife
8 LOT Basics A B Fiducial-Free Lung SBRT with CyberKnife
9 LOT vs. fiducial tracking 1 CT with fiducial, 2 CTs with LOT inhale and exhale Multiple tracking options with LOT that reduce PTV size from standard MIP Less reliance on criteria-based decisions, more on real-time imaging Fiducial-Free Lung SBRT with CyberKnife
10 4 LOT Tracking Options 2-view (Xsight Lung) Tracks tumor density instead of fiducials, robot breathes with patient 0-view (Xsight Spine) ITV based on tumor excursion Similar to MIP-based 1-view A, 1-view B Expands ITV only in blind view Robot breathes Fiducial-Free Lung SBRT with CyberKnife
11 Spine tracking vs Xsight Lung 0-view 2-view GTV: Gross Tumor Volume TUMOR TUMOR Subclinical Disease Subclinical Disease Healthy Tissue CTV: Clinical Target Volume PTV: Planning Target Volume Video courtesy of MD Anderson Fiducial-Free Lung SBRT with CyberKnife 11
12 ` Fiducial-Free Lung SBRT with CyberKnife
13 ` Fiducial-Free Lung SBRT with CyberKnife
14 ` Fiducial-Free Lung SBRT with CyberKnife
15 ` GTV E Fiducial-Free Lung SBRT with CyberKnife
16 ` GTV I Fiducial-Free Lung SBRT with CyberKnife
17 ` Fiducial-Free Lung SBRT with CyberKnife
18 ` Fiducial-Free Lung SBRT with CyberKnife
19 ` CTV E CTV I Fiducial-Free Lung SBRT with CyberKnife
20 ` CTV E ITV CTV I Fiducial-Free Lung SBRT with CyberKnife
21 ` ITV Fiducial-Free Lung SBRT with CyberKnife
22 ` PTV Fiducial-Free Lung SBRT with CyberKnife
23 ` Fiducial-Free Lung SBRT with CyberKnife
24 1-View A X-Ray Source A Tracked motion X-Ray Source B Untracked motion ITV & PTV Camera B Fiducial-Free Lung SBRT with CyberKnife Camera A Courtesy of Accuray
25 Distribution of LOT tracking ~25% Xsight Lung Remaining cases would have required fiducials or MIP-based PTV 1-view A 1-view B Xsight Lung Xsight Spine Fiducial-Free Lung SBRT with CyberKnife
26 Erlanger Workflow of LOT Fiducial-Free Lung SBRT with CyberKnife
27 1. CT Simulation Inhale and exhale scans required for LOT 1.5 mm for LOT DRR quality is critical Arms at side Fiducial-Free Lung SBRT with CyberKnife exhale imaging
28 2. CK Simulation Central to the LOT system Replaces criteria-based tracking qualification with image-based Fiducial-Free Lung SBRT with CyberKnife
29 Fiducial-Free Lung SBRT with CyberKnife
30 Fiducial-Free Lung SBRT with CyberKnife
31 Fiducial-Free Lung SBRT with CyberKnife
32 Fiducial-Free Lung SBRT with CyberKnife
33 Fiducial-Free Lung SBRT with CyberKnife
34 Fiducial-Free Lung SBRT with CyberKnife
35 Fiducial-Free Lung SBRT with CyberKnife
36 Fiducial-Free Lung SBRT with CyberKnife
37 3. Planning Doctor contours 2 GTVs, one on each CT 2-view requires only 1 GTV. No extrapolation needed. Fiducial-Free Lung SBRT with CyberKnife
38 3. Planning GTV + 3mm = CTV CTV + CTV = ITV ITV + 2mm = PTV LOT automated Margin protocol recommended from phase II clinical trial RTOG 0813 Fiducial-Free Lung SBRT with CyberKnife
39 3. Planning Beam blockers on arms, exit only No less than 20mm collimator 2-3 collimators, check fine tune Time Reduction No Fly Zone Timmerman, 2006 sequential OMI, OHI, OCO, MU 3 shells treatment time min Fiducial-Free Lung SBRT with CyberKnife
40 4. Treatment Typical Rx is 5400 cgy in 4 Fx Align to spine, move to lung Headrest, knee cushion, safety strap Headrest aids spine alignment Fiducial-Free Lung SBRT with CyberKnife
41 (10.5 movie) Fiducial-Free Lung SBRT with CyberKnife
42 v10.5 Treatment Software Fiducial-Free Lung SBRT with CyberKnife
43 Clinical Outcomes and 3 Year Follow-Up Data Fiducial-Free Lung SBRT with CyberKnife
44 3 Year Follow-Up Data 121 patients treated from April 2011 through October 2014; 44% male and 56% female Patient age ranged from years(mean: 74) Median follow-up was 10 months(range: 1-41) Tumor volume ranged from 0.4cc to 63.9cc, only one over 5cm in size; T1a=59pts, T1b=36pts, T2a=25pts,T2b=1pt. Fiducial-Free Lung SBRT with CyberKnife
45 3 Year Follow-Up Data A median dose of 54 Gy(45-60 Gy) delivered over 4 fractions(3-5 fractions) every other day Tumor control based on Kaplan-Meier analysis was 96.7% with 4 failures out of the total Overall survival was 47% at 36 months Fiducial-Free Lung SBRT with CyberKnife
46 3 Year Follow-Up Data 96.7% overall local control Fiducial-Free Lung SBRT with CyberKnife
47 3 Year Follow-Up Data Not statistically sig only 4 local failures Fiducial-Free Lung SBRT with CyberKnife
48 3 Year Follow-Up Data 47% overall survival Fiducial-Free Lung SBRT with CyberKnife
49 3 Year Follow-Up Data Only 10 months median follow-up Fiducial-Free Lung SBRT with CyberKnife
50 Pulmonary Function 1 year of PFTs show no detriment to lung function after LOT Fiducial-Free Lung SBRT with CyberKnife
51 Adverse effect risk models Chestwall risk model 10% risk = 47Gy Shows typical tolerance of 30cc < 30 Gy is conservative D70cc Fiducial-Free Lung SBRT with CyberKnife
52 Conclusion At Erlanger, the LOT system provides target accuracy and treatment effectiveness for early stage NSCLC without the use of fiducials. Fiducial-Free Lung SBRT with CyberKnife
53 Justin Richards, CMD RT(T) Gamma West Cancer Services Ogden Regional Medical Center
54 Speaker fee and travel paid by Accuray Incorporated The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.
55 Discuss blocking and other structures used for IMRT and 3D planning Discuss IMRT and 3D Planning with integrated boost Explore helpful tips and tricks, along with concerns for 3D Helical breast treatment planning
56 DLV: Dose Limiting Volume (extra structure) Directional Block: A block that will not allow beam to pass through it before it reaches the target. It will allow beam to pass through it after it has passed through the target Complete Block: A block that will not allow any beam to pass through it from any direction. Modulation Factor: The amount of Leaf movement allowed during treatment Pitch: The amount of overlap of each helical rotation (Lower Pitch = More overlap) Transitional Dose: The area where the dose changes from one amount to another.
57 For Breast: Pull PTV off of the skin surface by 3mm (This helps decrease skin reactions) For Chestwall: Pull PTV off of the skin surface by 2mm, or if higher skin dose is desired then leave it at skin surface For Integrated Boost: Leave a 5 mm gap between boost volume and breast target. This can help achieve a more homogenous dose throughout each target volume. Create 2 rings (inner and outer) Inner ring is 5 mm and stops at skin surface Outer ring is 1 cm and also stops at skin surface
58 Inferior DLV follows the inside of the rib cage below the lung. Superior DLV fills in the Mediastinum above the heart Block (Complete block) is a C shape from middle of contralateral breast around and into ipsilateral lung. Lateral DLV covers the area between the rings and the block laterally Medial DLV covers the area between the rings and the contralateral breast **The goal is to have all of the patient anatomy around the treatment area included in some type of contour These smaller contours give more control than just simply using the body as one big contour
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67 Work on lowering the dose to 2 or 3 structures at a time not all at once Use a modulation factor around 2.6 to start and increase or decrease it in increments of.2 as needed (I don t go any higher than 3.0) For better low dose DVHs, use a complete block It will lengthen the time, but the low dose areas do look better
68 Same PTV guidelines as IMRT For Breast: Pull PTV off of the skin surface by 3mm For Chestwall: Pull PTV off of the skin surface by 2mm, or if higher skin dose is desired then leave it at skin surface For Integrated Boost: Leave a 5 mm gap between boost volume and breast target. This can help achieve a more homogenous dose throughout each target volume
69 Block (Complete) follows inside of ribcage while staying 3 cm off of PTV Breast block (Directional block) Stays about 3.5 cm from medial border of breast Heart block (Complete) Mostly to block the left ventricle Direct block (Directional) Connects the breast block to the block
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75 Play with the design and location of your blocks Push blocks closer or pull them farther away Add or delete from the superior end Shrink the block on the superior end If you do not like the way the integrated boost looks, delete the block 1 cm above the boost volume to 1 cm below (leave the other blocks in place) The lung dose will increase a little, but the isodoses will conform better to the boost volume Bust out your inner child and get creative Blocks don t have to be created within the patient
76 3D Rt Breast Contralateral breast: V20 = 3, V5 = 40 Total lung: V20 = 11, V5 = 35 IMRT Lt Breast Contralateral breast: V20 = 3.5, V5 = 34 Total lung: V20 = 7, V5 = 30
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78 3D Chestwall plans are very similar to 3D Breast plans with blocking The difference is that there is no breast tissue for the dose to smooth out in, and the border of the chestwall PTV (at least for us) goes right to the lung interface This creates a problem with trying to keep lung doses to an acceptable level while still giving the prescribed dose to the PTV
79 To make an acceptable plan, there has to be some compromise in order to keep the lung dose, heart dose, and contralateral breast dose to an acceptable level What are you willing to compromise on? What is more important to you? PTV Coverage? Lung dose? Heart dose? Contralateral breast dose? Lunch?
80 3D DVH Comparisons Emphasis on:
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89 With good planning and the proper blocks, TomoTherapy does a great job in treating Breast cancer By pulling the PTV off of the skin, we see less skin reactions. We see redness, but very few cases of any type of desquamation If insurance will allow, IMRT plans definitely look better, but a very good plan can be achieved with 3D
90 Questions??? Justin Richards
91 Justin Richards, CMD RT(T) Gamma West Cancer Services Ogden Regional Medical Center
92 Speaker fee and travel paid by Accuray Incorporated The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.
93 Discuss blocking and other structures used for IMRT and 3D planning Discuss IMRT and 3D Planning with integrated boost Explore helpful tips and tricks, along with concerns for 3D Helical breast treatment planning
94 DLV: Dose Limiting Volume (extra structure) Directional Block: A block that will not allow beam to pass through it before it reaches the target. It will allow beam to pass through it after it has passed through the target Complete Block: A block that will not allow any beam to pass through it from any direction. Modulation Factor: The amount of Leaf movement allowed during treatment Pitch: The amount of overlap of each helical rotation (Lower Pitch = More overlap) Transitional Dose: The area where the dose changes from one amount to another.
95 For Breast: Pull PTV off of the skin surface by 3mm (This helps decrease skin reactions) For Chestwall: Pull PTV off of the skin surface by 2mm, or if higher skin dose is desired then leave it at skin surface For Integrated Boost: Leave a 5 mm gap between boost volume and breast target. This can help achieve a more homogenous dose throughout each target volume. Create 2 rings (inner and outer) Inner ring is 5 mm and stops at skin surface Outer ring is 1 cm and also stops at skin surface
96 Inferior DLV follows the inside of the rib cage below the lung. Superior DLV fills in the Mediastinum above the heart Block (Complete block) is a C shape from middle of contralateral breast around and into ipsilateral lung. Lateral DLV covers the area between the rings and the block laterally Medial DLV covers the area between the rings and the contralateral breast **The goal is to have all of the patient anatomy around the treatment area included in some type of contour These smaller contours give more control than just simply using the body as one big contour
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105 Work on lowering the dose to 2 or 3 structures at a time not all at once Use a modulation factor around 2.6 to start and increase or decrease it in increments of.2 as needed (I don t go any higher than 3.0) For better low dose DVHs, use a complete block It will lengthen the time, but the low dose areas do look better
106 Same PTV guidelines as IMRT For Breast: Pull PTV off of the skin surface by 3mm For Chestwall: Pull PTV off of the skin surface by 2mm, or if higher skin dose is desired then leave it at skin surface For Integrated Boost: Leave a 5 mm gap between boost volume and breast target. This can help achieve a more homogenous dose throughout each target volume
107 Block (Complete) follows inside of ribcage while staying 3 cm off of PTV Breast block (Directional block) Stays about 3.5 cm from medial border of breast Heart block (Complete) Mostly to block the left ventricle Direct block (Directional) Connects the breast block to the block
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113 Play with the design and location of your blocks Push blocks closer or pull them farther away Add or delete from the superior end Shrink the block on the superior end If you do not like the way the integrated boost looks, delete the block 1 cm above the boost volume to 1 cm below (leave the other blocks in place) The lung dose will increase a little, but the isodoses will conform better to the boost volume Bust out your inner child and get creative Blocks don t have to be created within the patient
114 3D Rt Breast Contralateral breast: V20 = 3, V5 = 40 Total lung: V20 = 11, V5 = 35 IMRT Lt Breast Contralateral breast: V20 = 3.5, V5 = 34 Total lung: V20 = 7, V5 = 30
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116 3D Chestwall plans are very similar to 3D Breast plans with blocking The difference is that there is no breast tissue for the dose to smooth out in, and the border of the chestwall PTV (at least for us) goes right to the lung interface This creates a problem with trying to keep lung doses to an acceptable level while still giving the prescribed dose to the PTV
117 To make an acceptable plan, there has to be some compromise in order to keep the lung dose, heart dose, and contralateral breast dose to an acceptable level What are you willing to compromise on? What is more important to you? PTV Coverage? Lung dose? Heart dose? Contralateral breast dose? Lunch?
118 3D DVH Comparisons Emphasis on:
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127 With good planning and the proper blocks, TomoTherapy does a great job in treating Breast cancer By pulling the PTV off of the skin, we see less skin reactions. We see redness, but very few cases of any type of desquamation If insurance will allow, IMRT plans definitely look better, but a very good plan can be achieved with 3D
128 Questions??? Justin Richards
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