Department of Radiation Oncology SMART. Stereotactic MR-guided adaptive radiotherapy. Marloes Jeulink Omar Bohoudi
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1 SMART Stereotactic MR-guided adaptive radiotherapy Department of Radiation Oncology Marloes Jeulink Omar Bohoudi
2 First clinical treatment May 4th 2016 First clinical treatment May 4 th 2016
3 MR-guided RT system: MRIdian MRI 0.35 T 70 cm bore 50 cm FOV Real-time imaging 4 FPS RT 3 Co-60 sources 550cGy/min Full divergent MLCs Tx =27cmx27cm TPS Monte Carlo Very fast Online ART SOURCE: VIEWRAY.COM
4 SOURCE: VIEWRAY.COM MR-guided RT system: MRIdian
5 SOURCE: VIEWRAY.COM The MRIdian Linac System
6 The MRIdian Linac System MRI 0.35 T 70 cm bore 50 cm FOV Real-time imaging 8 FPS SOURCE: VIEWRAY.COM RT 6 MV FFF >600cGy/min Double-Focused Double Stacked Tx =27cmx24cm Tx = 0.4x0.2cm TPS Monte Carlo Very fast Online ART
7 The MRIdian Linac RAYZR MLC DOUBLE FOCUSSED SOURCE: VIEWRAY.COM
8 Clinically available sequences Siemens 0.35T TrueFISP (Fast Imaging Steady-state Precession) T2/T1 ratio image contrast, fluids high signal X 1.5 mm = 172 sec (~ 3 min) X 3.0 mm = 25 sec Fast acquisition, less sensitive to motion X 1.5 mm = 172 sec (~ 3 min) SOURCE: VIEWRAY.COM 8
9 Image quality on the MRIdian
10 Image quality on the MRIdian Cranial Bladder wall Vesicles Fibromuscular zone Middle Apex Marginal zone Peripheral zone Neurovasc bundle Ischiorectal fossa
11 MRI safety 11
12 SMART patients Stereotactic MR guided Adaptive Radiation Therapy
13 Pre-treatment workflow Patient information Patient Positioning (Breathhold) CT+ MR Delineation GTV and OAR Adaptive Treatment plan generation QA
14 Patient immobilization
15 Classic workflow MR+CT Contouring Treatment planning QA treatment
16 SMART basis treatment plan Not an end product Point of departure for adaptive setting Basisplan MR Match Deformatie Recontouring Electron Density check Plan prediction Reoptimisation QA Treatment treatm
17 Treatment plan adaptive setting What doesn t change online: Physicians intent - prescription Beam angles Optimization objectives
18 Treatment plan adaptive setting What does change online: Anatomy MRI imaging Electron density Treatment planning structures Segments (amount, duration, shape) Dose distribution
19 Electron density
20 Electron density Deformable Fusion
21 Electron density
22 Electron Density online adaptive
23 Case study: electron density Simulation MRI
24 Case study: electron density MRI first fraction
25 Case study: electron density Elektron Density
26 Would you correct the electron density? Uncorrected electron density Corrected electron density
27 Case study: dose on electron Density
28 Contouring
29 Contouring
30 Contouring
31 Contouring
32 Contouring
33 Contouring
34 Contouring
35 Contouring
36 Contouring
37 Contouring
38 Isocenter location Limited by MR bore
39 Effects isocenter location
40 Imaging duringtracking
41 41 Beam group
42 Mridian IMRT optimalisatie
43 Robust plan objectives
44 SMART delivery workflow Patient positioning Pilot scan HR scan (breath-hold) Setup on GTV (rigid match) Project and deform OAR Independent QA Adapt plan Predict dose Electron density check Adjust deformed contours (within 3cm) Verificate positioning Set gating window (3mm) Treatment delivery (breathhold)
45 SMART delivery workflow 1. Patient positioning with coils 2. Perform pilot scan (23 sec) 3. Rough alignment with planning MRI 4. Select appropriate FOV 5. Perform high-resolution MRI ( 3 min) 6. Deform (and adapt) skin contour 7. Perform couch shift
46 Online adaptive strategy: contouring High-dose region matters most for toxicity (certainly in SBRT) Deformation is an aid, but not perfect Fast: patient is on table in treatment position Accurate: dealing with the relevant high dose region Manual adjustment of deformed OAR contours in area 3 cm outside the PTV
47 Improved sparing duodenum/ stomach Improved coverage GTV/PTV
48 Delivery video feedback system
49 Video feedback system
50 50
51 51
52 Smart components Positioning Scan & match Re-contouring* Re-planning* QA check* Treatment time 2 min 16 min * 5 min * * 8 min 9 min 7 min
53 PRO-Q responses first 150 patients Was it difficult to control the target by holding your breath? Was it confronting to see your tumor during the treatment? Did you like having an active role during treatment? Not at all A bit Moderate Considerable Did you worry about your contribution to the treatment? 0% 20% 40% 60% 80% 100%
54 PRO-Q responses first 150 patients Anxiety Noise Cold yes considerable Paresthesia Heat Dizziness Metallic taste Light sensations 0% 20% 40% 60% 80% 100%
55 Thank you Chair: Ben Slotman Clinicians: Anna Bruynzeel Suresh Senan Niels Haasbeek Swie Swat Oei Shyama Tetar Frank Lagerwaard Clinical Physicists: Miguel Palacios Tezontl Rosario Marjan Admiraal Johan Cuijpers Technicians: Daan Hoffmans Karel de Jong Frank de Geest Dosimetrists: Omar Bohoudi Jessica Oudeboon Robin Botman Roosje Bakker Emile Koper Paul Duijvenvoorde Ruud de Moes Marloes Jeulink Lisanne Labee
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