The TomoTherapy System as a Tool of Differentiation in Quality and Marketability

Transcription

1 The TomoTherapy System as a Tool of Differentiation in Quality and Marketability John J. Kresl, MD, PhD, FACRO, FACR Medical Director Phoenix CyberKnife & Radiation Oncology Center Managing Partner Phoenix, Arizona Chief Clinical Officer Select Healthcare Solutions Rancho Santa Fe, CA Chief Medical Officer Alliance Oncology, US Radiosurgery Newport Beach, CA

2 Disclosure The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred. An honorarium is provided by Accuray for this presentation.

3 Agenda TomoTherapy Cases TomoTherapy connectivity to HER /OIS TomoTherapy clinical pathways and patient utilization

4 IMRT, IGRT, SRS, SBRT Experience >5000 SRS treatments >4750 SBRT treatments 1997 Peacock/Corvus IMRT program 1997 Gamma Knife program 2003 CyberKnife program 2003 Novalis Brainlab program 2006 TomoTherapy program 2006 Varian Trilogy program 2009 Elekta Axesse program 2009 Novalis Tx with RapidArc program 2011 CyberKnife VSI program 2011 TrueBeam STx with RapidArc program 2013 CyberKnife M6 program 2014 TomoTherapy HDA program

5 Introduction Palo Verde installed the 500 th TomoTherapy System

6 Case load at Palo Verde Commonly treated cases: breast, CNS, head and neck, sarcoma, lung, and GI Average treatment time: 6-7 minutes Can easily treat approximately 25 patients/day, in an 8 hour day The majority of our patients are treated with 3-D conformal TomoHelical treatment plans and IMRT

7 Case Examples

8 CASE V-M: Whole Brain with 3-D TomoHelical 65-year-old woman, metastatic NSCLC to the brain 30 Gy at 3 Gy/fraction using 3-D TomoHelical Excellent sparing of the oral cavity, anterior orbits, and lens Excellent homogenous dose with a maximum dose Gy Patient tolerated the treatment very well, no significant side effects other than fatigue Excellent dose homogeneity and lower maximum doses means chronic alopecia is not as common

9 CASE K-W: Head and Neck IMRT 59-year-old man, squamous cell carcinoma of unknown primary of the head and neck Complex dose painting treatment plan (in 33 fractions): Gross disease (PTV70.29): Gy at 2.13 Gy/fraction Ipsilateral neck (PTV63): 63 Gy at 1.91 Gy/fraction Contralateral neck(ptv57.75): Gy at 1.75 Gy/fraction Entire mucosa extending from nasopharynx to hypopharynx (PTV54): 54 Gy at 1.64 Gy/fraction

10 CASE K-W: Head and Neck IMRT The plan provided excellent coverage while respecting normal tissue tolerances: Spinal cord max dose = 38.3 Gy Brainstem max dose = 36.6 Gy Bilateral parotid: Mean dose = ~23 Gy V30Gy: 24% and 26% Oral cavity mean dose = 42 Gy Mandible max dose = 66.5 Gy Esophagus: Mean dose = 20.3 Gy V50Gy = 28% V35Gy = 30% The patient tolerated the treatment very well without treatment breaks Parotids Cord

11 Scalp This is a 77-year-old male with squamous cell carcinoma of the left forehead. The skin cancer was treated with TomoHelical 3-D to 50 Gy at 2.5 Gy/fraction for 20 fractions. A 1-cm bolus was used with 6 MV photons. Treatment plan: 95% of the volume received the prescribed dose of 50 Gy. The hotspot was 54.6 Gy, within the treatment volume. The patient tolerated the treatment extremely well. He developed brisk erythema in the irradiated field without desquamation. The skin changes resolved within 2 weeks of treatment.

12 Retroperitoneal Sarcoma This is a 81-year-old male who presented with a 40 cm retroperitoneal sarcoma. The patient was treated with postoperative radiation therapy secondary to positive margins throughout the circumference of the tumor. The entire post-operative bed was treated with IMRT 45 Gy at 1.8 Gy/fraction for 25 fractions. This was followed by a boost to the areas of greatest concern by the surgeon; these areas received an additional 16 Gy at 2 Gy/fraction for 8 fractions. Considering the extent of the treatment field and the proximity to many organs, the homogeneity of the plan was excellent.

13 Retroperitoneal Sarcoma The plan provided excellent coverage while still respecting normal tissue tolerances: Spinal cord max dose = 36.8 Gy Total lung V20 = 12.7% Heart mean dose = 12.9 Gy Liver: V25Gy = 62% V30Gy = 44% Small Bowel: V30Gy = 207 cc Bladder PTV45 PTV61 V45Gy = 26 cc Liver V50Gy = 2.1 cc Max dose = 54.1 Gy Left Kidney: V18Gy = 3.6% Lt Kidney Small Bowel V22Gy = 0.5 cc Bladder: V60Gy = 22% V40Gy = 44%

14 Connectivity

15 Accuray Oncology Information System (OIS) Interfaces High-Level Functionality Import TomoTherapy plan information and set up treatments in OIS Schedule TomoTherapy treatments in OIS calendar Record and track TomoTherapy treatments in OIS Complete procedure and charge capture for TomoTherapy treatments Important Note: The TomoTherapy System includes its own built-in record and verify (R&V) functionality. Therefore, when interfacing the TomoTherapy System with an OIS, the OIS provides additional treatment recording and other supporting functions. The TomoTherapy System continues to provide the R&V function.

16 TomoTherapy plan exported to ARIA Query ARIA for Procedure List Procedure List sent to TomoTherapy Treatment Record sent to ARIA TomoTherapy -ARIA Interface: Updated Workflow Overview TomoTherapy System 1 Plan created and approved 9 Patient treated 11 Treatment recorded in TomoTherapy database ARIA 2 Patient record created 4 Plan imported and set up in ARIA 5 Treatments scheduled 6 Patient checked-in 12 Treatment/dose recorded & accumulated in ARIA 13 Procedure / charge capture completed Before Treatment Day of Treatment Workflow illustration for TomoTherapy H Series software (Hi Art 5.1.0) with ARIA 11 or higher

17 Workflow and Efficiency

18 TomoTherapy System Throughput: US Sites Site Selection for January 2015 data Studied all US sites with useful log data on February 4, 2015 (172 sites) Eliminated logs >30 days old (guarantees most data is from January 2015) Sites with idle time between patients >15 minutes (primarily research sites) Looked for top 10 sites by Largest median # of patients per day Smallest median time between patients Consider top 10 as best-practice examples; compared to average over all Americas sites included in sample Trending over time Gross metrics of median time between patients, and median patients per day Radiation Oncologists Part # of Central Arizona

19 Significant increases in throughput, Significant increases in throughput, "Top 10" Sites in the Americas: Median Time Between Patients The most efficient sites in the Americas now average <15 minutes between patients "Top 10" Sites in the Americas: Median # of Patients per Day The most efficient sites in the Americas now average >32 patients per day Based upon summary data from calendar years shown

20 Typical Durations for Stages of Treatment Initial Setup MVCT Beam-On Time Patient Registration Register-to- Treat Treatment Beam-On Time Idle Time Between Patients Palo Verde throughput comparable to best in US idle time will decrease as we add more patients * Based upon calendar year 2014 data obtained from machine logs ** Based upon 30-day logs retrieved 04 Feb 2015 primarily data from January 2015

21 Conclusions

22 TomoTherapy System effective and efficient in single-vault center Handles majority of cases we see well Patients typically needing electron treatment can be treated Higher beam energy is not necessary for deep-seated abdominal lesions Short treatment times, high throughput possible TomoTherapy has been very reliable Down for service for two days in 1.5 years Interface with Aria allows efficient, accurate workflow Integrated nature and straightforward QA is valuable in a single-vault center Conclusions

23 Thank you!