8/1/2018. Clinical Experience with Automated Multicriteria Optimization. Ben Heijmen, Sebastiaan Breedveld. Disclosures

Transcription

1 8/1/218 Clinical Experience with Automated Multicriteria Optimization Ben Heijmen, Sebastiaan Breedveld Joint AAPM-ESTRO Symposium: Automated Treatment Planning in Clinical Practice AAPM 218, Nashville Disclosures Erasmus MC Cancer Institute has research agreements with Elekta AB (Stockholm, Sweden) and Accuray Inc (Sunnyvale, USA). Elekta AB is preparing commercialization of the approach for automated multi-objective planning. Clinical Experience with Automated Multicriteria Optimization Outline Validation of automatic planning: comparison with manual Reduction of bias and enhancement of patient numbers in planning studies for treatment technique comparisons Challenges and Future 1

2 Dose in OAR 2 head-and-neck prostate cervix Prostate SBRT S. Breedveld et al. Med Phys. 212; 39(2): S. Breedveld et al. Med Phys. 212; 39(2): /1/218 Pareto front unacceptable plan acceptable plan Craft et al. - a posteriori MCO: user selects final, clinically favourable plan - a priori MCO: system automatically selects the final, clinically favourable plan on Pareto front Dose in OAR 1 tumor site specific wish-lists contoured CT-scan ErasmusiCycle automatically generated Plan Plans: Pareto-optimal clinically favourable balances (apriorimco) Constraints wish-list for prostate cancer Volume Type Limit PTV Max dose % of DPx PTV Mean dose 1% of DPx Rectum & Anus Max dose 2% of DPx PTV Shell mm Max dose % of DPx Unspecified tissues Max dose % of DPx Objectives Priority Volume Type Goal Parameters 1 PTV LTCP.8 DPx = 78 Gy, α =.8 2 Rectum EUD 2 Gy k = 12 3 Rectum EUD Gy k = 8 4 PTV shell mm Max dose 8% of DPx Skin ring 2 mm Max dose 2% of DPx Rectum Mean dose Gy 6 Anus Mean dose Gy 7 Bladder Mean dose Gy 8 PTV Shell 1 mm Max dose % of DPx PTV Shell 2 mm Max dose 3% of DPx 9 Left & Right Femoral Heads Max dose % of DPx same wish-list used for all patients (no patient-specific tweaking) 2

3 8/1/218 Generation of wish-lists: improve on training plans definition of initial wish-list based on: - planning protocol - review of recent clinical plans - discussions with clinicians and planners for limited number of training patients (~): automated plan generation with based on current wish-list update current wish-list YES evaluate plans plan quality enhancement feasible? NO final wish-list = current wish-list Highlights of : automatically one Pareto-optimal plan, clinically favourable trade-offs, OAR doses as low as feasible no operator dependence of plan quality, consistently high huge reduction in planning workload Highlights of : automated beam profile and beam angle optimization versions for lmrt/vmat, Cyberknife and protons (version for BT being developed, AAPM 218, Kolkman-Deurloo et al.) highly suited for unbiased treatment technique comparisons; automated planning with same wish-list 3

4 head-and-neck head-and-neck prostate prostate cervix cervix Prostate SBRT Prostate SBRT 8/1/218 Clinical implementation Clinical implementation tumor site specific wish-lists contoured CT-scan ErasmusiCycle automatically generated Plan Clinical implementation tumor site specific wish-lists commercial TPS: Monaco (Elekta linacs) Multiplan (Cyberknife) contoured CT-scan ErasmusiCycle patient-specific template commercial TPS automatically generated Plan 4

5 8/1/218 is in routine clinical use for VMAT and IMRT: Head-and-neck cancer Cervical cancer () Prostate cancer Advanced lung cancer (~4% of curative patients) Clinical Experience with Automated Multicriteria Optimization Outline Validation of automatic planning: comparison with manual Reduction of bias and enhancement of patient numbers in planning studies for treatment technique comparisons Challenges and Future Validation of automated planning based on Head and neck cancer Prostate and seminal vesicles Prostate and vesicles and lymph nodes Prostate SBRT with Cyberknife Gastric cancer Spinal metastases Cervical cancer Advanced lung cancer Pubmed: Heijmen b*

6 B. Heijmen et al. Radiother. Oncol. 218 Jun 3, in press 8/1/218 Head and Neck cancer Int J Radiat Oncol Biol Phys. 213; 8(3): in 97% of cases the automatic plan was selected by physician for treatment manvmat lower autovmat lower 4 European centers 8 prostate patients (prostate + vesicles) manvmat autovmat lower lower B. Heijmen et al. Radiother. Oncol. 218 in press AUTOplan vs. MANplan for prostate cancer blinded clinician s side-by-side plan scoring AUTO ++ AUTO + 38 pts: autovmat better with high impact EQUAL MAN + MAN ++ 9 pts: manvmat better with high impact Number of patients 6

7 8/1/218, patients Prostate SBRT Cyberknife L. Rossi et al. Acta Oncol. 218 July 2: published on-line, in press Clinical Experience with Automated Multicriteria Optimization Outline Validation of automatic planning: comparison with manual Reduction of bias and enhancement of patient numbers in planning studies for treatment technique comparisons Challenges and Future Issues with treatment planning studies for treatment technique comparisons Planning is manual, i.e. interactive, trial-and-error Different planning skills/experience for different treatment techniques Different TPSs for different techniques bias in treatment technique comparisons low patient numbers 7

8 8/1/218 Reduce bias, enhance patient numbers with : Fully automated planning for all techniques Same TPS, same optimization engine/schedule (wish-list) for both techniques Prostate SBRT: VMAT vs. Cyberknife Automatically generate 3 plans for 2 patients: 1. CK, 3 mm CTV-PTV margin (as clinical, tumor tracking) 2. VMAT, mm margin (no tracking, no rotation correction) 3. VMAT, 3 mm margin (clinically not feasible) L. Rossi et al. Acta Oncol. 218, in press prostate SBRT prostate SBRT Linac, VMAT Cyberknife non-coplanar IMRT Multiplan : Breedveld, Heijmen, et al, Med Phys. 39(2), p , 212 8

9 L. Rossi et al. Acta Oncol. 218 July 2: published on-line 8/1/218 Blinded clinician s side-by-side plan comparisons Radiother Oncol. 217;123(1): patients - VMAT - VMAT+1, VMAT+2, VMAT+ - NCP-1, NCP-2 9

10 248 fr1 fraction fr1 248 fr2 ST666 fr2 137 fr2 248 fr3 ST666 fr3 137 fr3 Isocenter shift IMRT re-optimization IMRT & Beam angle re-optimization 8/1/218 2-NCP VMAT+3 VMAT 29 liver SBRT: IGRT vs. daily adaptive re-planning Int J Radiat Oncol Biol Phys. 213 Dec 1;87():16-21 Results Modest impact of daily beam angle re-optimization

11 head-and-neck head-and-neck prostate prostate cervix cervix Prostate SBRT Prostate SBRT 8/1/218 Clinical Experience with Automated Multicriteria Optimization Outline Validation of automatic planning: comparison with manual Reduction of bias and enhancement of patient numbers in planning studies for treatment technique comparisons Challenges and Future Clinical implementation tumor site specific wish-lists contoured CT-scan ErasmusiCycle patient-specific template commercial TPS automatically generated Plan Clinical implementation tumor site specific wish-lists contoured CT-scan TPS (CE, FDA, ) automatically generated Plan 11

12 8/1/218 intensive upfront time investment of doctors automation no planning work personnel reduction for planning Erasmus MC contributors: Sebastiaan Breedveld, Abdul Sharfo, Linda Rossi, Rens van Haveren, Bas Schipaanboord, Rik Bijman, Ybing Wang, Andras Zolnay, Erik-Jan Tromp Steven Habraken, Patricia Cambraia Lopes Ferreira, Maarten Dirkx, Wilco Schillemans, Joan Penninkhof, Steven Petit, Inger-Karine Kolkman, Mischa Hoogeman, Erica Venema, Christa Timmermans, Alejandra Mendez, Luca Incrocci, Jan-Willem Mens, Gerda Verduyn, Marjan van de Pol, Cecile Janus, Joost Nuyttens, Ben Heijmen and many (inter)national collaborators 12

13 8/1/218 13