Implementation of Gynaecological IMRT Planning Technique Clinical Guidelines and Constraints. Chloe Pandeli

Transcription

1 Implementation of Gynaecological IMRT Planning Technique Clinical Guidelines and Constraints Chloe Pandeli 1

2 Session Name: Proffered papers - Gastrointestinal / Gynaecological In accordance with the policy of The Royal Australian and New Zealand College of Radiologists, the Australian Institute of Radiography and the Australasian College of Physical Scientists and Engineers in Medicine the following presenter has indicated that they have a relationship which in the context of their presentation, could be perceived as a real or apparent conflict of interest but do not consider that it will influence their presentation. The nature of the conflict is listed: None

3 Session Name: Proffered papers - Gastrointestinal / Gynaecological The presenter has advised that the following presentation will NOT include discussion on any commercial products or service and that there are NO financial interests or relationships with any of the Commercial Supporters of the 2014 Combined Scientific Meeting.

4 Background Endometrial cancer - 6 th most common malignancy in women - Most diagnosed at an early stage - Most patients aged over 60 years 1 4

5 Diagnosis of Endometrial cancer Post-operative RT recommended No gross residual disease Patient Eligibility No extensive serosal involvement of uterus, tubes or ovaries Patient able to comply with bladder and bowel preparation instructions 3 5

6 Benefits of IMRT Several advantages of IMRT compared to conventional radiotherapy - Less dose to OARs Clinical targets -Pelvic lymph nodes and vaginal vault OARs - Bladder - Rectum - Small bowel - Femoral head and neck 4 6

7 Experienced staff Available technology - Planning - Treatment Why implement IMRT? 7

8 Implementation of IMRT for endometrial cancer at Epworth Staff selected for implementation - RO, RTs, Physics, Nursing Meetings with RO Protocols for planning and treatment - Based on RTOG 0418 Staff training Development of templates in eclipse 8

9 Patient care path Initial appointment - RO consultation - RT discussion re bladder and bowel preparation Simulation appointment Patient positioned supine with personalised vacfix 2 CT scans with vaginal contrast - Empty bladder - Full bladder 9

10 Contouring Guidelines based on RTOG 0418 protocol Target volumes -Nodal CTV & PTV -Vaginal ITV & PTV OARs RT - Contours to assist with optimisation 10

11 Planning 50.4 Gy in 28 Fx 7 field IMRT technique (eclipse planning system) 10MV photons Dose constraints based on RTOG 0418 trial Developed in-house templates and guidelines 11

12 IMRT vs. 4 field Conventional Patient 1 4 field IMRT Small bowel (V40Gy 30%) 41.7% 22.03% Rectum (V30Gy 60%) 79.2% 60.9% Bladder (V45Gy 35%) 98.6% 45% Femur R (V30Gy 15%) 36.0% 6.44% Femur L (V30Gy 15%) 55.2% 4.99% Patient 2 4 field IMRT Small bowel (V40Gy 30%) 13.0% 3.3% Rectum (V30Gy 60%) 97.4% 56.9% Bladder (V45Gy 35%) 84.1% 23.5% Femur R (V30Gy 15%) 60.0% 6.2% Femur L (V30Gy 15%) 60.0% 7.5% 12

13 IMRT vs. 4 field 13

14 Compromise Difficulty maintaining bladder filling towards the end of treatment 2-5 fold increase in monitor units per treatment 14

15 Workload Implications Increased time - Simulation - Contouring - Planning - Physics QA - Treatment 5 15

16 Conclusion IMRT for endometrial cancer has been successfully implemented Protocols and guidelines successfully adapted Treatment well tolerated by patients OARs receive lower doses than conventional RT The expectation is that with longer follow up, our patients will record reduced late side effects Preliminary outcomes - low toxicity rates and excellent pelvic control Future considerations - Use of fiducial markers - Dose escalation 16

17 Acknowledgements Dr. Bronwyn King ERO 17

18 References Ahamad A, Jhingran A, 2004 New Radiation Techniques in gynecological cancer International Journal of Gynecological Cancer, 14: Harris E, Latifi K, Rusthoven C, Javedan K, Forster K, (2011) Assessment of organ motion in postoperative endometrial and cervical cancer patients treated with intensitymodulated radiation therapy Int Journal of Radiation Oncology, Bio, Phys 81(4): e645-e650 Jhingran A, Winter K, Portelance L, Miller B, Salepour M, Gaur R, Souhami L, Small W, Berk L, Gaffney D, (2012) A Phase II study of Intensity modulaed radiation therapy to the pelvis for postoperative patients with endometrial carcinoma: Radiation Therapy Oncology Group Trial 0418, Int Journal of Radiation Oncology, Bio, Phys 84(1): e23-e28 Roeske JC, Lujan A, Rotmensch J (2000) Intensity modulated whole pelvis radiation therapy in patients with gynecologic malignancies, Int Journal of Radiation Oncology, Bio, Phys 48: Salama K, Roeske J, Mehta N, Mundt A, (2004) Intensity-modulated Radiation Therapy in Gynecologic Malignancies Current Treatment Options in Oncology, 5: Shih K, Milgrom S, Abu-Rustum N, Kollimer M, Gardiner G, Tew W, Barakat R, Alektiar K, (2013) Postoperative pelvic intensity-modulated radiotherapy in high risk endometrial cancer Gynecologic Oncology 128: Wagner A, Jhingran A, Gaffney D, (2013) Intensity modulated radiotherapy in gynecologic cancers: Hope, hype or hyperbole Gynecologic Oncology 130: Wright J, Medel B, Sehouli J, Fujiwana K, Herzog T, (2012) Contemporary management of endometrial cancer The Lancet 379: ) 2) 3) 4) 5) 18