Use of SpaceOAR for Prostate Radiotherapy Preliminary Report

Transcription

1 Date: April Use of SpaceOAR for Prostate Radiotherapy Preliminary Report Soon N. Huh (ho), Ph.D., DABR University Of Florida Health Proton Therapy Institute (UFHPTI) Presented to the Florida Chapter of AAPM, Orlando, Florida

2 Thank you so much for invitation

3 Nothing to Declare

4 Contents 1. CT/MR Marker (Gold Anchor) 2. SpaceOAR T MR Simulator * Pediatric and Various Immobilizations * Prostate 4. Prostate Proton Therapy 5. Planning Guidelines 6. Delivery and Follow-ups 7. Preliminary Conclusion

5 Gold Anchor and Its Inventor Gold Anchor Dr. Ingemar Naslund Associate Professor, Karolinska Institute Sweden

6 Special Thanks to Dr. Ingemar Naslund

7 Gold Anchor : 99.5% Gold + 0.5% Iron Gold Anchor has 0.28mm advantages 0.48mm Special Thanks to Dr. Ingemar Naslund

8 Choice of Marker Configuration Straight marker * Useful for detecting plastic deformations and tilting gives very little artifacts on CT * Has low affect on the dose distribution in proton therapy * Visible with kv, CBCT and ultrasound Completely folded marker * Suitable when using tracking system * Visible also with MVCT (e.g Tomotherapy) 8

9 Gold Anchor vs Conventional Marker in CT Special Thanks to Dr. Ingemar Naslund

10 Gold Anchor on DRR DRR kv image not matched with DRR kv image matched with DRR Special Thanks to Dr. Ingemar Naslund

11 Rad A and B in in Proton Unit Rad-A : SAD==151.1cm Rad-B : SAD=287.5cm

12 2 Markers in CT images and 0.23T T1 MRI Plan CT 0.23T T1 MRI (phase 1)

13 Gold Marker vs VisiCoil in 3T MR Images Gold Anchor Gold Anchor VisiCoil

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15 What about 0.23T? Head Coil; Body Coil; H&N with Body Coil > 2,200 scans > 100 scans > 40 scans For pediatric patients who receive proton therapy: (i) No anesthesia or sedation (ii) no contrast (iii) no special hardwares (iv) Faster Scan (at most 9 min) (v) parent or social worker stays with pt

16 Diagnostic MRI with C+ vs 0.23T T1 MRI with C- Diagnostic MR 1.5T T2 MR with C+ 1.5T Diagnostic T1 MR with C+ UFPTI T1 MR 0.23T T1 MR with C- Note: They are used to evaluate image fusion (Contrast CT, and UFPTI T1 MR)

17 Craniopharingioma in 0.23T T1 MRI

18 3T vs 0.23T 0.23 T vs 3T 3T Diagnostic T1 MR 3T Diagnostic T2 MR 0.23T ~T2 MR (BFFE3D)

19 0.23T MR images of Healthy Spines MR-based Dosimetry

20 Motion Study of Prostate from UFPTI Note 1: Saline (100cc) in Rectum Note 2: B-FFE-3D with frame rate of 2 sec (~2.5min scan time)

21 Phase One MR Imaging

22 3 Markers in CT images and 0.23T T1 MRI

23 Without Compression Device Co-registered Patient Images CT T1 MR (phase 1) SpaceOAR T2 MR (phase 1) SpaceOAR 4/8/2016

24 3T vs 0.23T T1 MRI (before and after implants) Diagnostic 3T MR images (before implants) Gas SpaceOAR 0.23T MR images (Phase One)

25 SpaceOAR 1. Procedure 2. Phantom Study with Publix Meat 3. Patient Study

26 Prostate-rectum Spacing Transperineal Implantation Pre implant space 3 month persistence 6 month absorption Axial T2 MRI images Liquid Hydrogel precursors injected through 18G needle Solid Hydrogel maintains prostate rectum separation during radiotherapy Liquid Hydrolysis liquefies gel which is absorbed within 6 months Polymerizes in 10 sec Breaks down by Hydrolysis Special Thanks to Tom Guest, Augmenix, USA

27 SpaceOAR System Application PEG (poly ethylene glycol) hydrogel chemistry Injected: Solidifies: Persistence: Absorbs: 18G, liquid hydrogel precursors within 10 seconds lasts about 3 months Within ~6 months Gel polymerization Water based polymer Does not heat up during polymerization Breaks down via hydrolysis Flows through perirectal fat, locking it in place Special Thanks to Tom Guest, Augmenix, USA

28 SpaceOAR in Water: Hydrolysis 2 months later (in the water) Very brittle, just 1 min after it was made.

29 Procedure: Synthetic Absorbable Hydrogel Spacer (total 15cc solution) 18G Needle with US (axial and sagittal US images) Hydrodissection fluid (5cc saline) Inject to peri-rectal fat (mid-gland and mid-line, create space for Gel) Mix polymer with 5cc diluent (Precursor, 5cc) Shake Accelerator Syringe (5cc) (Help to make Gel. Called Salt Buffer Solution ) Mixing in Y-connection Inject to peri-rectal fat (mid-gland and mid-line) Soft Hydrogel

30 SpaceOAR System Application Ultrasound Video VIDEO Clip Special Thanks to Tom Guest, Augmenix, USA

31 US Pivotal Study Summary Reliable Space Creation 99% Procedural Success Significant Rectal Dose Reduction 73.5% reduction in rv70 Rectal DHV Results Meaningful Clinical Benefits Late toxicity reduction Bowel QOL benefits Odds for late rectal toxicity 25% 20% 23.3% 17.1% Control SpaceOAR Control Group SpaceOAR Group (1 in 14.2 patients) (1 in 49.3 patients) 15% 10% 5% 0% 12.2% 11.7% 6.8% 4.2% 3.3% 0.6% rv50 rv60 rv70 rv80 Grade 1 < Grade 3 Special Thanks to Tom Guest, Augmenix, USA

32 Shift in Rectal V70 Distribution Number of patients Histogram of Rectal V70 Distribution SpaceOAR Group Before and After Spacer Application rv70 Pre Spacer rv70 Post Spacer The Control Group rectal V70 distribution was excellent relative to the literature. Spacer application shifted the distribution, with 88 patients in the 0-3% rectal V70 range. Rectal V70 (%) Special Thanks to Tom Guest, Augmenix, USA

33 Planning Considerations Dose Volume (%) 60% 50% 40% 30% 20% 10% 0% Rectal Tissue Constraint Evolution 79.2 Gy x 44 Fractions RTOG DCRT < 50% QUANTEC IMRT < 50% SpaceOAR IMRT < 35% < 35% < 25% < 25% < 15% < 20% < 15% < 5% < 4% * < 3% < 2% < 1% Gray * Proposed rectal dose constraints for spacers by Rajecki et al, Dose plan optimization when using hydrogel prostate-rectum spacer: a single institution experience. Submitted for publication Perirectal Space + Optimized planning = Low rectal doses Special Thanks to Tom Guest, Augmenix, USA

34 MR Imaging 1. Bench Mark : 1.5, 3T Imaging for Prostate 2. Immobilizations : The most critical factor! 3. Imaging for Gold Marker 4. Motion Study for Smearing Margin for Proton 0.23T MR Simulator, and a minor compression

35 How Much 0.23T MR Simulator Could Do? 1. Prostate Motion Study 2. Craniopharyngioma 3. Spine Imaging 4. Spine Imaging with Metal Implants 5. Eye Scan for Melanoma What about Prostate Scan with Gold Anchor and SpaceOAR?

36 Motion Study of Prostate: Saline in Rectum Note: BFFE3D with frame rate of 2 sec

37 MR Scanning for (1.5 to 20yo) Peds 1. No Anesthesia/Sedation 2. No MR Contrast 3. No Commercial Immobilization 4. House-made Immobilization

38 Craniopharyngioma patients ( 0.23T BFFE3D Note 1: T1 (5 min) and BFFE3D (6 min) images of adult craniopharyngioma Note 2: See details in 0.23T BFFE3D images (looks like use a pencil, and draw organs)

39 3T vs 0.23T 0.23 T vs 3T 3T Diagnostic T1 MR 3T Diagnostic T2 MR 0.23T ~T2 MR (BFFE3D)

40 0.23T MR images of Healthy Spines MR-based Dosimetry

41 Metal Implants with 0.23T II (~4 min in each scans) CT Omar CT 2D T1 TSE With 0.23T 2D T2 TSE With 0.23T 3D BFFE3D

42 Prostate MR Images 1. Marker Detection : T1, BFFE3D images 2. SpaceOAR : T1, T2, Fat Suppression 3. T1 and T2 images * T2: prostate, SV, penile gland (poor SNR in 0.23T) * T1: marker, other organs Note: SpaceOAR ~= water eq. (in electron density and SPR, CT # = 10)

43 Optimization of MR Sequences for SpaceOAR and CT/MR Marker Dr. Curtis Bryant On 0.23T MR Scanner

44 MRI for SpaceOAR and X-Mark Markers (T1, BFFE3D, and T2 with no motions) CT1 T1 BFFE3D T2

45 Abdominal Compression Device with 0.23T Scanner For SpaceOAR Prostate Patient Air pump with pressure meter Note: The thermoplastic supporter prevents the compressor from moving inferior

46 Marker Detection without Compression prostate/bladder and breathing motion

47 0.23T T1 MRI: Marker, and SpaceOAR 3T T1

48 T2 TSE Images (under Progress)

49 3 MRI: T1, T2, and Fat Suppression T1 T2 IR T2 Note 1: Gold Anchors are visible in T1 Note 2: Compression device can affect patient setup?

50 A minor Compression Device Can affect Patient s Geometry? 12 phase-array body coil for 3T coil head set Note 1: it does NOT prevent motions for obese patients

51 Proton Prostate Treatments * Modality: DS, US (IMPT under progress) * Imaging : DIPS (CBCT: under Progress) * ABC (for lung, pancreatic ca.) * Future: 0.5T MRI

52 Proton Therapy of Prostate Cancer BCFP MSK 1 UFHPTI 2 IMRT (PR010203) benchmark UFHPTI 3 OTP (2Gy/fx) Low risk 97% 99% Int risk 85% 99% 95% High risk 67% 76% 76% 1 Spratt et al, 2013, IJROBP. Long-term survival and toxicity in patients treated with high-dose intensity modulated radiation therapy for localized prostate cancer patients with IMRT 2 Mendenhall et al, 2014, IJROBP. Five-year outcomes from 3 prospective trials of imageguided proton therapy for prostate cancer. 221 patients (80 intermediate risk, 40 high risk) 3 Bryant et al, 2016, IJROBP. Five-year biochemical results, toxicity, and patient-reported quality of life following delivery of dose-escalated image-guided proton therapy for prostate cancer patients with 551 Intermediate risk and 229 High Risk patients. 4/8/2016

53 In the Beginning of SpaceOAR 60Gy 50% (39 for 78) Note: 4mm (CTV to PTV), and 7mm (PTV to Aperature)

54 Procedure 1. Immobilization: Blue Bag 2. CT Simulation / MR Imaging with 0.23T 3. Planning with Eclipse 4. Treatment with DS/US (OTP: 2 CGE / fx and 78CGE) 5. Follow-ups during RT: Verification with CT and MRI

55 Immobilization 1. Blue Bag 2. Rectum (a) Saline (100c) into Rectum and VisiCoil (since 2007) (b) Rectal Balloon and VisiCoil (since 2010) (c) SpaceOAR (no rectal balloon) and Gold Anchor (sine Feb 2016) DVH Low Risk with Balloon V70=7cc for Hypo-fractionation

56 Prostate Motions for PTV 1. Wireless Transponder (Calypso System) 2. Repeat CBCT (before and after photon treatment) 3. X-ray Imaging 4. Cine MRI Cine MR, and X-ray (PreRT and PostRT for 4 to 5 min)

57 Prostate PT: Minimizing PTV Margins A PTV margin was calculated to allow CTV coverage in 95% of treatments for 90% of patients (van Herk, IJROBP, 2000) Assuming setup error bounded within +/- 2 mm with daily orthogonal imaging and VisiCoil markers Assuming prostate intra-fraction motion of 2 mm in 5 min (Cine-MR study) PTV margin = 4 mm axial and R/L and 6 mm cranial-caudal How to identify the ~10% patients with larger intra-fraction prostate motion magnitude? 4/8/2016

58 Prostate Imaging Policy Room scheduling 1. During first 10 days of treatment, perform post-tx DIPS imaging 2. Inform treating physician if calculated post-tx correction values larger than 4 mm (< 1 out of 10 expected) 3. Record correction values 4. After first 10 days, perform weekly post-tx imaging 5. Re-plan if 2 out-of-tolerance intrafraction movements recorded. 4/8/2016 In-Room Patient Setup Motion Monitoring and control Completion of Treatment

59 Further Reduction Of Prostate PTV Margin Zeitlin et al, Int J Particle Therapy, 2015: Review of treatment images of 40 low-risk prostate patients treated from With rectal balloon: 2 mm lateral, 3 mm AP/PA; 3 mm Sup/Inf With rectal saline injection: 2 mm lateral; 4 mm AP/PA; 4 mm Sup/Inf Implementation of reduced margins for prostate PT in progress With Belly Compression (like MR Scan)? With CBCT? With on-board MRI (0.5T, future)? 4/8/2016

60 DIPS: AP and Lateral X-ray Rad-B (SAD = ~280cm) Rad-A (SAD = ~150cm)

61 Gold Markers in DIPS 0.48mm and 10mm

62 Differences of 3 Seeds between PreRT and Post RT in X-rays (in cm) (with Rectal Balloon and VisiCoil during ~4min) 1.6mm in 3D

63 Motions of Prostate from PreRT and PostRT (with Rectal Baloon and VisoCoil) Total Number of X-rays

64 Prostate Motions with DIPS before and after Tx (with Space OAR, and Gold Anchor, ~4min) Rectal Balloon and VisiCoil Increase by ~0.5mm in 3 coords!

65 Preliminary Conclusion Previous Data show that SpaceOAR reduce motions w/o rectal baloon??. Not enough data? If so, a minor compression can reduce motions?

66 Movie with SpaceOAR: with Sagittal Images

67 Movie with SpaceOAR: with axial images

68 Smearing Margin 1. Range Uncertainty : 1.5mm 2. Organ Motion : assume to be ~2mm (4 min) 3. Setup Uncertainty 4. CT SPR s uncertainty : ~3% All together, SM = 1.4cm We could reduce the SM (mainly item 2 and 3)

69 Compensator smearing I Margin for range uncertainty due to motion, deformation, setup errors High density Heterogeneity Target Beam OAR Compensator Body surface Aperture Thanks to Dr. Stella Flampouri

70 Compensator smearing II Margin for range uncertainty due to motion, deformation, setup errors 1.4cm Target Beam OAR Compensator Body surface Aperture Thanks to Dr. Stella Flampouri

71 Optimization Procedure Aperarture Range Compensator 1.4cm Gantry Selection Gantry Selection

72 DVH of Planning

73 Final Dose Distributions Note 1: Smearing Margin (SM = 1.4cm) Overshoot Note 2: How much we can reduce the SM?

74 Beam Delivery I SpaceOAR and VisiCoil Rectal Balloon and Gold Anchor

75 Beam Delivery II 4min procedure Beam Deliver

76 Differences of 3 Seeds between PreRT and Post RT in X-rays (in cm) (with Rectal Balloon and VisiCoil during ~4min) 1.6mm in 3D

77 CT and Verification MRI (T2) with 0.23T CT 2 hr after implant Week 1 Week 2 Week 3 Note: less sensitive to rectal filling?

78 DVH: V70Gy of Rectum 2.3cc +/- 2.1cc

79 Why 5.3cc?

80 Verification 1. CT or MR images: 3 weeks 2. Image fusion 3. Run Verification Plans, and Get DVH Data

81 Rectum Changes: Example (due to gas buildup) Rectum at W1 R D=70CGE = 16.2% (max deviation) SpaceOAR 16% Rectum at Plan (R D=70CGE = 2.7%) DVH Constraints: R D=70CGE = 30%

82 Preliminary Conclusion 1. Learning curve to make SpaceOAR useful in RT 2. We found out that (a) SpaceOAR is reproducible (b) Less sensitive to Rectal Filling or Gas?! (c) Intra-Fraction Motions could be smaller (d) Immobilization during MRI is a must 3. Image Fusion is more accurate (a) More reliable fusion with Seed Matching (b) Smaller margin: intra or inter-fraction motion (c) Seed Migration is minimum (?) 4. Less Dose Perturbation during proton planning 5. More Rectum Saving Dose Escalation? 6. Hypo-frationation?

83 Questions 1. SpaceOAR can cause less motions from rectal motion? 2. A minor compression device can cause anatomical changes? 3. A minor compression device could reduce block (AP) margins? 4. We can reduce smearing margins? 5. We could inject more SpaceOAR to take care of SV? * more than 15cc? * We can include markers into SpaceOAR? * We need to remove Gas? 6. Hypo-fractionation?

84 Special Thanks to 1. Tom Guest, Augmenix, USA 2. Dr. Ingemar Naslund, Karolinska Institute, Sweden 3. UFHPTI Physicians * Drs. Nancy Mendenhall, Curtis Bryant, Randy Henderson * Dr. Z Li, E Vivier * Dr. Matt Hall 4. UFHPTI Therapists * Trevor Flemming, Noelle Ziegelbauer, Monica Ferriby

85 Thank You so much for your attention

86 Appendix

87 MRI in RT Diagnostic Radiology MRI Neurosurgery Physics RT Question: Who is going to cover this Black Hole?

88 CSF Pulsation From Internet Note: so many organs in terms of different susceptibility, and motions, and interface.

89 MR Phantom with BFFE3D Acrylic phantom human mandible with teeth water corn oil Acrylic pipe

90 Diagnostic MRI with C+ vs 0.23T T1 MRI with C- Diagnostic MR 1.5T T2 MR with C+ 1.5T Diagnostic T1 MR with C+ UFPTI T1 MR 0.23T T1 MR with C- Note: They are used to evaluate image fusion (Contrast CT, and UFPTI T1 MR)

91 Fast Cranio: 3 patients (< 2 yo)

92 1.5T T1 Custom-made House-made Head Head Rest Rest 0.23T T1 : W1 With commercial head rest 0.23T T1 : W2 With new home-made head rest 0.23T T1 : W3

93 MR-safe Headset for Immobilization and MUSIC for <8 yo peds Volume control 1.5T T1 1.5T T2 0.23T ~T2

94 MR Immobilization fro Adult Patient Ear Muffs: uniform contacts pressure Before inflation After inflation

95 Craniopharyngioma patients ( Contrast CT 0.23T T1 0.23T BFFE3D Note 1: T1 (5 min) and BFFE3D (6 min) images of adult craniopharyngioma Note 2: See details in 0.23T BFFE3D images (looks like use a pencil, and draw organs)

96 Craniopharingioma in 0.23T T1 MRI

97 3T vs 0.23T 0.23T vs 3T 3T Diagnostic T1 MR 3T Diagnostic T2 MR 0.23T ~T2 MR (BFFE3D)

98 0.23T MR images of Healthy Spines MR-based Dosimetry

99 Metal Implants with 0.23T II (~4 min in each scans) CT Omar CT 2D T1 TSE With 0.23T 2D T2 TSE With 0.23T 3D BFFE3D

100 MR Images of Spine for SBRT 1.5T Diagnostic MR images (Dixon sequence) UFPTI Images

101 Tumor Modeling for Proton Eye Tx 0.23T with a gazing device 1.5T Diagnostic MR images w/o a gazing

102 Geometrical Distortion with house-made phantom Due to non-linearity of gradient magnetic field

103 Distortion-Free MR Images Distorted images Plan CT 2D T1 Routine 2D T2 TSE 3D BFFE3D Note: septum in BFFE3D image!!!

104 T1 for Sarcoma in Right Pelvis