University Medical Center Utrecht The Netherlands

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1 University Medical Center Utrecht The Netherlands Metha Maenhout, MD: PHD student Maaike Koelink: Specialist RTT Wilfred de Vries: Physicist Assistant MED [00]

2 UMC Utrecht

3 Radiotherapy Department 11 Elekta Linacs (6 Agility and 5 MLCi) equiped with conebeam CT and/or Megavolt Imaging

4 Radiotherapy Department 1 MR-linac (Research) and 3 MRL s to build (Clinical) (aprox. end of 2014)

5 Radiotherapy Department 1 Bigbore CT (Philips) and Tesla MRI (Philips) 3 MR s to build (2x 1.5 Tesla and 1x 3.0 Tesla)

6 Radiotherapy Department 1 Orthovoltage machine to treat superficial tumours

7 Radiotherapy Department Organization: 24 radiation oncologists + 11 arts in opleiding 9 Physicists + 6 Physicist Assistants 6 Linac Engineers 25 PHd students +/- 140 RTT s

Radiotherapy Department Clinical activities: +/- 4000 new patients every year All tumour-sites are treated,

8 Radiotherapy Department Clinical activities: +/ new patients every year All tumour-sites are treated, but mainly: Mamma Prostate Gynaecology Head and Neck Lung. with techniques: mainly IMRT and VMAT VMAT Pancreas

9 Brachytherapy Brachy-team: 10 Radiation Oncologists 2 Physicists 2 Physicist-Assistants 15 Radiation Technologists

10 Brachytherapy Ir-192: 1 HDR and 2 PDR-machines. All Nucletron Microselectrons I-125: Seedselectron (Nucletron) Stranded seeds (Best Medical)

11 Brachytherapy Planningssystems: Oncentra Brachy Oncentra Prostate

12 Brachytherapy Indications: Mainly: Gynaecology (HDR and PDR) Prostate Cancer (I-125 and HDR) Other indications: Oesophagus Keloid Head and Neck Anal canal.

13 Brachytherapy Applicators: Utrecht Applicator

14 Brachytherapy Applicators:

15 Brachytherapy Prostate protocol: LDR: 1 x 144 Gy with I-125 seeds on prostate+margin HDR: 1 x 19 Gy focally/salvage on CTV+margin

16 Brachytherapy Team Roles: Rad. Oncologist: - Insertion of needles - Delivering of seeds Technologist: -Treatment planning - Preparation stranded seeds - Execute HDR treatment. Physicist(-Assistant): - QA and calibration

17 Future for Radiotherapy MR-linac MR-HIFU by J.J.W. Lagendijk by M.A.A.J. van den Bosch

18 Future for Brachytherapy Prostate implant with Robotic Device By M.R. van den Bosch

19 Department Radiotherapy

20 Capital District Health Authority Nova Scotia Cancer Center Dr. David Bowes, Radiation Oncologist Dr. Krista Chytyk-Praznik, Physicist Dr. Mammo Yewondwossen, Physicist Educational Workshop organised by St James s Institute of Oncology, Leeds in association with Nucletron Leeds, UK, 5 th and 6 th November 2013

21 Leeds, UK, 5 th and 6 th November, 2013

22 Radiotherapy Department Overview Treatment infrastructure: External: Novalis/TrueBeam STx radiosurgery system TrueBeam STx 2100iX 2100EX 2100CD V600 (2) Brachy: Nucletron microselectron Digital Imaging: GE CT Sim Varian Acuity MRI, PET-CT (DI) Leeds, UK, 5 th and 6 th November, 2013

23 Radiotherapy Department Overview Radiation oncologists 11 Physicists (RT) 10 Physicists (DI) 2 Dosimetrists 6 Radiation Therapist (technologist) 50 Radiation Oncology Residents 4 Medical Physics Resident 1 Leeds, UK, 5 th and 6 th November, 2013

24 Radiotherapy Department Overview We treat ~2300 courses a year Or ~34,000 fractions Participate in: RTOG, COG, NCIC and other trials Leeds, UK, 5 th and 6 th November, 2013

Active research programs CARBON TARGET IN CAROUSEL

targets Allows volume-of-interest CBCT for IGRT 3-4x

PHOTONS: YELLOW Robotic iris technology for VOI CBCT

in image guidance Algorithms for optimization of bolus

25 Active research programs CARBON TARGET IN CAROUSEL Industry collaboration on low-atomic number linac targets Allows volume-of-interest CBCT for IGRT 3-4x increase in CNR relative to MV imaging ELECTRONS: BLUE PHOTONS: YELLOW Robotic iris technology for VOI CBCT Facilitates improved image quality and dose reduction in image guidance Algorithms for optimization of bolus design in e- therapy Incorporation of 3D printing technology into RT process

26 Brachytherapy Overview Number of staff involved in brachytherapy 3 Rad Onc 7 therapists 3 Physicist 2 RN Involved in a Brachy case: 2 Therapists ( 1 therapist is trained to perform the "scrub" role in the OR) 2 RN's 1 Rad Onco 2 physicists 2 recovery room nurses 1 ward aide 1 anesthesia tech 1 anesthesiologist Leeds, UK, 5 th and 6 th November, 2013

27 Brachytherapy Overview Disease indications/patient types, number of patients treated with brachytherapy per year Diaease /Sites Ca Cervix : Ring/Tandem or Ovoid and Tandem or Cylinder and Tandem Ca Endometruim: Cylinders Ca Vulva: Mupit template with Proguide or metal needles, Blind end Interstitial catheters Ca Esophagus: Esophageal Applicator Ca Prostate to start soon: Nucletron Stepper /template with BK medical ultrasound We currently treat about 50 patient/year Leeds, UK, 5 th and 6 th November, 2013

28 Brachytherapy Overview Brachytherapy infrastructure: Brachytherapy Suite Image with Varian Acuity simulator (CBCT) Nucletron HDR microselectron Digital after loader Oncentra Brachy Planning System Leeds, UK, 5 th and 6 th November, 2013

29 Brachytherapy Overview Protocols Cervix: 4500cGy/25 external beam with 6-7 Gy x 4 Brachy given weekly starting after 3 weeks of external beam Endometrium: 4500cGy/25 external beam with 1100cGy/2 Brachy given weekly after 3 weeks of external beam Esophagus: 800cGy/1 Leeds, UK, 5 th and 6 th November, 2013

30 Current procedure Brachytherapy Prostate: 15 G in single treatment Roles: RadOnc: Insertion of applicators/ implant Contour CTV Approval of plan Present for treatment Removal of implant/applicators Physicists: Treatment planning QA of treatment plan Present for treatment Therapists: OR Scrub role Acquire necessary imaging Treatment delivery RN Prostate Leeds, UK, 5 th and 6 th November, 2013

31 Objectives Learn from your experience Start Real-time image guided HDR brachytherapy treatment for prostate Leeds, UK, 5 th and 6 th November, 2013

32 King Chulalongkorn Memorial Hospital Petch Alisanant,MD. Radiation Oncologist Educational Workshop organised by St James s Institute of Oncology, Leeds in association with Nucletron Leeds, UK, 5 th and 6 th November 2013

33 Radiotherapy Department Overview Machines Conventional simulators : 1 CT simulators : 1 (2 in 2014) MRI simulators : 2 (1.5 T) LINACS : 3 (6 in 2014) Brachytherapy machine : 1 (Ir-192) Leeds, UK, 5 th and 6 th November, 2013

34 Radiotherapy Department Overview Organization Thai Red Cross Society Radiation oncologists : 13 Physicists : 8 RTT : 20 Leeds, UK, 5 th and 6 th November, 2013

35 Radiotherapy Department Overview 1,500 in patients beds,university Hospital 3,000 new cancer patients/year 2,500 new RT patients/year Leeds, UK, 5 th and 6 th November, 2013

36 Brachytherapy Overview 3 staffs involved in brachytherapy Most of patients are cervical cancer 200 cases/year Brachytherapy infrastructure: C-arm X-ray : 5% CT sim : 5% MRI sim : 90% One OR Multichannel brachytherapy machine Leeds, UK, 5 th and 6 th November, 2013

37 Current procedure Brachytherapy Prostate We use only EBRT for prostate cancer. Brachytherapy Prostate : training process Leeds, UK, 5 th and 6 th November, 2013

38 Objectives To start brachytherapy in prostatic cancer in our institution. Leeds, UK, 5 th and 6 th November, 2013

39 St Luke s Cancer Centre, Guildford Dr Sara Khaksar (Consultant Oncologist) Mrs Mel Cunningham (Brachytherapy Physicist) Educational Workshop organised by St James s Institute of Oncology, Leeds in association with Nucletron Leeds, UK, 5 th and 6 th November 2013

40 Radiotherapy Department Overview 6 Varian Linacs 2 more being installed in Satellite centre Gulmay Orthovoltage unit 1 HDR (TRUS and stepper) 2 CT scanners 1 more being installed in satellite centre Papillion 50 Eclipse/Prosoma for EBRT planning Oncentra Brachy HDR planning Variseed seed planning Leeds, UK, 5 th and 6 th November, 2013

41 Radiotherapy Department Overview 20 Oncologists 3 currently performing LDR prostate brachytherapy 18 Physics staff (including 2 dosimetrists) 3 with responsibilities in brachytherapy Leeds, UK, 5 th and 6 th November, 2013

42 Brachytherapy Overview Prostate LDR 3 Oncologists/ 1 Urologists/2 Research fellows 1 Oncologist/1 Urologist Up to 300 patients treated per year usingi-125 seeds Prostate Brachytherapy infrastructure: B&K Ultrasound/ExIIStepper Dedicated (but small) Operating theatre & team Variseed TPS Access to CT scanners HDR 1 oncologist with significant interest and involvement Gynae 20 Cx/yr 80 Vaginal Cylinders HDR Oesophageal introduced (3 since July) HDR rectal introduced (3 since July) Leeds, UK, 5 th and 6 th November, 2013

43 Current Procedure Brachytherapy Prostate LDR I-125 seed implants Monotherapy 145 Gy Boost 110 Gy (Following 44 Gy/22# EBRT) Roles Urologist/Oncologist Outline of prostate/insertion of seeds Physicist- Order/calibration/preparation of seeds Real-Time Plan Source accounting/log QC Leeds, UK, 5 th and 6 th November, 2013

44 Objectives HDR Prostate- Learn How to Perform technique so that when business case is approved we can introduce quickly More information for business case!!! Leeds, UK, 5 th and 6 th November, 2013

I. Equipments for external beam radiotherapy

I. Equipments for external beam radiotherapy 5 linear accelerators (LINACs): Varian TrueBeam 6, 10 & 18 MV photons, 6-18 MeV electrons, image-guided (IGRT) and intensity modulated radiotherapy (IMRT),