IMAT: intensity-modulated arc therapy

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1 : intensity-modulated arc therapy M. Iori S. Maria Nuova Hospital, Medical Physics Department Reggio Emilia, Italy 1 Topics of the talk Rotational IMRT techniques: modalities & dedicated inverse-planning (IP) modules. modalities & new accelerators with variable dose-rate (vdr). IMRT,, (vdr) & Tomotherapy () modalities: Some reflections from the Literature. Plan comparisons between, and (vdr) techniques: Dosimetric and radiobiological analysis of prostate tumor plans simulated with both modalities. treatments and gating: A preliminary experience. 2 1

2 Acknowledgement SMN Hospital Physics Department: Dr. Elisabetta Cagni Dr. Marta Paiusco Dr. Silvana Riccardi Dr. Laura Marras Dr. Emanuela Morabito Mr. Lambertini Daniele Mr. Nicola Bizzocchi Dr. Gianni Borasi (Director) External collaborations: Prof. Alan Nahum, Bebingtom,, UK Prof. Eugene Wong, Western Ontario, CA Dr. A. Gladwish,, Western Ontario, CA Dr. Mauro Cattaneo,, Milano, IT Dr. Claudio Fiorino,, Milano, IT Ing.. Marco Foracchia,, Reggio E, IT 3 Fluence-modulation technique: a summary Static IMRT: SMLC method Static IMRT: DMLC method Robotic IMRT: CyberKnife 1/3 Dose 1. MLC field Set-Up 1/3 Dose 2/3 Dose 2. MLC field Set-Up 1/3 Dose 3. MLC field Set-Up By courtesy of BrainLab By courtesy of Borasi G By courtesy of ACCURAY Rotational IMRT: Serial Tomotherapy (ST) Rotational IMRT: Helical Thomotherapy () Rotational IMRT: Intensity-Modulated Arc Therapy () By courtesy of NOMOS By courtesy of Tomotherapy By courtesy of VARIAN 4 2

3 limits without inverse-planning tools Better dose-distribution distribution on target volume (PTV) H&N 1% 9% 5% 2% Better dose sparing of normal tissues (organs at risk) Prostate No Optimization With Optimization No Optimization With Optimization Chen JZ, ICCR 24 By courtesy of Chen JZ 5 New inverse-planning modules 2 step method Conventional two step method: to optimize e the beam intensity maps and to decompose them into a number of segments. The DAO method A faster DAO approach Shepard DM, MP 22 The new DAO (Direct Aperture based Optimization) approach: to pre-assign a pre -specified (by aperture-based segmentation tools) number of field apertures and optimised directly the shapes (together with the machine MLC constraints) and weights (MUs or dose-rates) of the apertures. DAO applied to SMLC created highly conformal IMRT plans using between 3 and 7 apertures per beam direction. DAO capability generally do not converge rapidly to an optimal solution due to delivery constraints: long optimization times. Otto K, Varian

4 The need of a variable dose-rate during the accelerator arc deliveries Earl MA, PMB 23 PTV PTV PTV OAR OAR OAR For all actual plans the gantry rotation speed or the dose rate are restricted to be constant. However, changing either the gantry speed or dose rate during gantry rotation, tion, a noticeable improvement in the critical structure DVH is evident,, while the target (PTV) gains only slightly. As alternative, others arcs can be are added to simulate the effect fect of allowing the gantry speed to vary or the dose rate to change during the delivery: the cost of this solution is the additional time required to deliver the additional arcs. 7 New accelerators for rotational IMRT VMAT: Volumetric Modulated Arc Therapy MUs MLC shape By courtesy of Varian Company & L. Cozzi 8 4

5 VMAT vs. static 7F IMRT: an example The clinical case The VMAT plan dose parameters are slightly better than fixed 7F IMRT plan. What about VMAT vs.? More & systematic studies on different tumours and patient groups are necessary. By courtesy of Varian Company & L. Cozzi, Bellinzona, CH 9 vs. IMRT and Tomotherapy IMRT (vdr( vdr) Yu C, TCRT 26. 9A Solid: Dashed: IMRT Spinal cord Parotids CTVs 9F 9A & 16A Kraienbuehl K, RO 26 & Cao D, IJROBP 27 (vdr( vdr) 9A 1 5

6 Delivering Tomo () plans as After Tomotherapy planning, an plan is generated by a leaf sequencing algorithm (BUS), which converts the sinogram (opening times for each leaf at each projections) into MLC files, to verify either an alternative treatment courses (conventional accelerator) or for Tomotherapy back-up strategy Tomo 33Gy The plans with BUS sequencer are approximations (more( or less equivalent and clinically acceptable) of the original plans Tomotherapy Gy (BUS) 1A Gladwish A, Med Phys 27 By courtesy of A. Gladwish, Western Ontario, CA 11 vs. : a group of prostate treatments THE GOL To evaluate how therapy, optimized with an inverse-planning approach, can approximate the Helical Tomotherapy () plans for a group of patients with prostate tumour. THE MATERIAL Six prostate tumors treated with the were simulated with an planning to which was added an optimization approach based on an inverse-planning module. To have similar beam-on times ( 6min, 7.1min), for the modality 6 arcs (6MV) were defined. Sagittal slice Overlap SVdst PTV2 PTV3 SVprx PTV4 Prostate Transversal slice Femoral head Bladder Protocol at S. Raffaele Hospital (Milan, Italy) Dose prescription Prostate PTV4 SVprx PTV3 SVdst PTV2 Overlap Dose per fraction (Gy) Bulb Rectum 12 6

7 (In-house) * arc-sequencing method for 39 fixed beams equally spaced SMLC-IMRT algorithm Choice of the arc number 1 Arc number vs. MU for degree 1.5 Total MU value (for all arcs) Total MU MU/ MU / degree Arc number. Reduction of the segments number Reduction of the different MU values *: MatLab software realized by Cagni E, ASMN 13 Mean target and normal tissue DVH's 1 PROSTATE 1 OVERLAP 1 PROX. SEM. VESICLES RECTUM NORMAL TISSUES TARGETS 1 DIST. SEM. VESICLES BLADDER 1 PENILE BULB 1 HEALTH TISSUES BLUE: / RED: Tomotherapy ()

8 & : dose curve comparison Tomotherapy () : better coverage of target volumes and more dose homogeneity : improvements (less doses) in normal tissue sparing 15 & : radiobiological evaluation The comparison of all patient plans has been done using the Equivalent Uniform Doses (EUD) EUD1 (% ) EUD / patient variations (NTCP RECTUM=5%) Plan comparison of the average values for the different target volumes PRST () PRST () OVLP () OVLP () EUD /=1 patient variations (NTCP RECTUM=5%) 74. SVPX () SVPX () SVDT () SVDT () Patients EUD1 (%) 7. PRST () PRST () OVLP () OVLP () PRST OVLP SVPX SVPX () SVPX () SVDT () SVDT () Target volumes SVDT 16 8

9 with variable Dose-Rate All plans have been compared after the rectum volume NTCP (5%) normalization 5. EUD max (/ /=1.5, 3, 1) DMEAN(Gy) DMEAN (for all different target volumes) + vdr Different treatment modalities + vdr: therapy simulated (3arcs) with variable Dose-Rate and gantry rotation speed NTCP: normal tissue complication probability. EUD: equivalent uniform dose. TCP: tumour control probability. TCP (%) EUD (Gy) Different treatment modalities TCP ( /=1, 3) with NTCPRECTUM=5% /=1 + vdr /=3 Different treatment modalities + vdr + vdr Iori et al., RO Dosimetry of plans with/without gating Motion MLC Motion data: amplitude: ± 2cm period: 4sec FIX FIX GATING NO-GATING Maximum absolute doses differences (1-15%) and isodose curves distortions (1-2cm) are present without gating even for treatment similarly to IMRT. By courtesy of M. Paiusco, S. Riccardi, ASMN 18 9

10 A short history of photons & technology AT FIRST appears capable of further improvements over 3DCRT and non-helical IMRT in the specific avoidance of critical normal structures. [Welsh JS; Patel RR; Kron T; 22]. A good correlation exists between the quality of the plans (complex( lungs) and the IMRT plans, with being slightly better in most cases [Kron[ T 24]. NOT LONG AGO If planning could be optimised, we expect the technique to achieve dose distributions that rival both ST and non-rotational IMRT. [Yu CX, IJROBP 22]. A large window for improvement exists for : plan optimisation on and improvement of the linac control software. [Duthoy[ W, IJROBP 23]. TODAY can be considered the current gold standard in IMRT delivery.. Our initial comparison confirmed that could serve as a true alternative to.. [Yu C, TCRT 26] For most cases, can provide plan qualities comparable to that of. For some intracranial tumours ( non-coplanar) led to significant dosimetric improvements., however, can provide improved dosimetric results in the most complex cases. [Cao D, IJROBP 27] TOMORROW? New accelerators with 3D arc modulation capabilities? Proton-therapy therapy facilities with arc modulation capabilities? 19 1

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