From verification to adaptive plan: A discussion on workflow and procedures with case study examples

Transcription

1 From verification to adaptive plan: A discussion on workflow and procedures with case study examples

2 THANKS! My Planning team: Maynak Amin Cody Crawford Manny Oyervides Katina Crabtree David Lege Rola Georges Rachel Hunter Tyler Williamson Physics Support: Falk Poenisch Ron Zhu Richard Wu Special Thanks: Jaques Bluett Matt Palmer Lei Dong

3 Despite our best efforts, problems and situations can arise:

4 Outline: - Recognize an issue (Verification) - Basic terms and procedures - Correct the plan (Adaptive Plan) - Terms - Workflow - ROI validation and deformation - Putting it all together - Case studies - Lung - Head and Neck - Lessons learned

5 Verification Planning: What is a verification plan? - A verification plan is procedure in which a new CT is acquired. - That CT is registered to the original plan CT. - Then the original plan is copied and pasted onto the newest scan. - The dose is recomputed, but no re-optimization.

6 Verification Planning: What is a verification plan? - A verification plan is procedure in which a new CT is acquired. - That CT is registered to the original plan CT. - Then the original plan is copied and pasted onto the newest scan. - The dose is recomputed, but no re-optimization. The purpose of this verification is to certify the plan is being delivered within specifications

7 Verification Planning: What is a verification plan? - A verification plan is procedure in which a new CT is acquired. - That CT is registered to the original plan CT. - Then the original plan is copied and pasted onto the newest scan. - The dose is recomputed, but no re-optimization. The purpose of this verification is to certify the plan is being delivered within specifications If the plan has migrated too far from the nominal plan, an adaptive plan is generated.

8 Verification Planning: What is a verification plan?

9 What is an adaptive plan? Adaptive planning is the process in which a new plan is generated and used for the remainder of treatment.

10 Why do we do Adaptive planning? - Typically adaptive plans are performed for situations that can potentially overdose a critical structure or underdose a target volume. (ex. volumetric changes within patient)

11 Why do we do Adaptive planning? - Typically adaptive plans are performed for situations that can potentially overdose a critical structure or underdose a target volume. (ex. volumetric changes within patient)

12 Why do we do Adaptive planning? - Typically adaptive plans are performed for situations that can potentially overdose a critical structure or underdose a target volume. (ex. volumetric changes within patient) - They can also be performed to correct any setup or reproducibility issue. - Or any other situation that physician/physics deems necessary to alter the current plan of treatment.

13 How are Adaptive plans performed? New CT Acquisition: - Typically a new CT data set is acquired and registered with the original planning CT (reference CT). Reference CT

14 How are Adaptive plans performed? New CT Acquisition: - Typically a new CT data set is acquired and registered with the original planning CT (reference CT). Reference CT Re-sim data set

15 How are Adaptive plans performed? New CT Acquisition: - Typically a new CT data set is acquired and registered with the original planning CT (reference CT). - We register based on boney alignment (ex. vertebral bodies in thorax) Reference CT Re-sim data set Register

16 How are Adaptive plans performed? New CT Acquisition: - Typically a new CT data set is acquired and registered with the original planning CT (reference CT). - We register based on boney alignment (ex. vertebral bodies in thorax) - Once a registration is established, minor adjustments can be made looking at orthogonal DRRs between the new and ref CT. Reference CT Re-sim data set Register Minor Adjustments

17 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made.

18 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - Often times a verification plan will be performed to validate plan robustness. - The verification plan is the original plan copied onto a more current CT and dose recomputed (no re-optimization at this time)

19 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - **Physician must evaluate the targets, as changes to the patient can be dramatic**

20 How are Adaptive plans performed? New Target Volumes: **Physician must evaluate the targets, as changes to the patient can be dramatic**

21 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made.

22 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - **Physician must evaluate the targets, as changes to the patient can be dramatic**

23 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - **Physician must evaluate the targets, as changes to the patient can be dramatic** - Traditionally the physician has copied the original targets and made modifications manually.

24 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - **Physician must evaluate the targets, as changes to the patient can be dramatic** - Traditionally the physician has copied the original targets and made modifications manually. - In the future, deformable registration software may become a popular aide for physician in defining volumes that have changed.

25 How are Adaptive plans performed? New Target Volumes: - Deformable software can be a time saver and help predict tumor changes. If deformable software is used, we still require physician review final contours before planning.

26 How are Adaptive plans performed? New Target Volumes: - Once the new CT has been registered, the physician will determine if the original planning volumes are valid, or if modifications need to be made. - **Physician must evaluate the targets, as changes to the patient can be dramatic** - Traditionally the physician has copied the original targets and made modifications manually. - In the future, deformable registration software may become a popular aide for physician in defining volumes that have changed. - Normal tissues are re-contoured on the new data set.

27 How are Adaptive plans performed? Planning: - After planning targets have been verified and new normal tissues drawn, planning can begin. - The adaptive plan generally uses the same methodology as the original approved plan (beam angles, some objective, etc.) - Typically turn around time for the adaptive plan is relatively quick, as we want to implement the new plan.

28 How are Adaptive plans performed? Planning: - The adaptive plan is planned to the full Rx for ease of DVH evaluation. - Once the planner deems the re-plan clinically acceptable a plan sum or composite will be created. - The plan sum consists of the original plan (Rx scaled to number of fractions given) and the new plan (Rx scaled to remaining number of fractions. - The sum plan will be displayed on the new scan.

29 How are Adaptive plans performed? Planning: - In the future, deformable dose algorithms may be used to create more accurate plan sums.

30 How are Adaptive plans performed? Plan Review: - Once the plan sum has been created, the physician can review the plan. - Typically the physician reviews both the new plan to full fractions and the composite plan sum during plan review. - Once the plan is approved normal processing and QA procedures can be performed

31 Case Study: Passive Proton Planning CT with original treatment volumes

32 Case Study: Passive Proton Adaptive CT with new treatment volumes

33 Case Study: Passive Proton Lung Cord Original Approved Plan

34 Case Study: Passive Proton Lung Cord Verification Plan (original plan on Re-Sim data set)

35 Case Study: Passive Proton Lung Cord Final adapted plan composite

36 Case Study: Scanning Beam 3 Target volumes Original Approved Scanning plan

37 Case Study: Scanning Beam 3 Target volumes Verification Plan (original plan on Re-Sim data set)

38 Case Study: Scanning Beam Original target DVH DVH of original plan and Verification plan

39 Case Study: Scanning Beam 3 Target volumes Final Adapted plan composite

40 Case Study: Scanning Beam Composite SUM DVH and Original DVH

41 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed.

42 Things we have learned: Pleural Effusion example

43 Things we have learned: Pleural Effusion example

44 Things we have learned: Pleural Effusion example

45 Things we have learned: Pleural Effusion example

46 Things we have learned: Pleural Effusion example

47 Things we have learned: Pleural Effusion example

48 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed.

49 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed. - Volumetric changes of target can be an indicator that adaptive plan will be needed (CBCT)

50 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed. - Volumetric changes of target can be an indicator that adaptive plan will be needed (CBCT) - The earlier an adaptive plan is implemented the more effective the adaptive plan will be

51 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed. - Volumetric changes of target can be an indicator that adaptive plan will be needed (CBCT) - The earlier an adaptive plan is implemented the more effective the adaptive plan will be - Implementing adaptive plan towards end of treatment is much less effective optimal time is midway through treatment.

52 Things we have learned: - Observing fluid in the lung at the time of planning can be an indicator that additional monitoring (verification CTs) might be needed. - Volumetric changes of target can be an indicator that adaptive plan will be needed (CBCT) - The earlier an adaptive plan is implemented the more effective the adaptive plan will be - Implementing adaptive plan towards end of treatment is much less effective optimal time is midway through treatment. - Weight loss can be a trigger that may warrant a verification/adaptive plan.

53 Questions? Thank You! Cody Wages