Intracavitary + Interstitial Techniques Rationale
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1 Vienna, May, 2018 Intracavitary + Interstitial Techniques Rationale Primoz Petric NCCCR, HMC, Doha
2 Dimensions of prescribed dose: different levels Prescribed dose Standard loading Modified loading 18 mm Level A + 2 cm A A Point A 20 mm Ring sources 26 mm Example: Stockholm style Tandem & Ring applicator 30 mm ring 60 mm intrauterine tandem 30 mm
3 Dimensions of prescribed dose: different levels Prescribed dose Standard loading Modified loading 21 mm Level A + 2 cm A A A 24 mm Ring sources 30 mm Example: Stockholm style Tandem & Ring applicator 30 mm ring 60 mm intrauterine probe 34 mm
4 Intracavitary Techniques A
5 Intracavitary Techniques EBRT? Boost needed... A Interstitial?
6 EBRT Boost: Planning Study I 6 patients Box EBRT MRI guided IC BT AP-PA Boost IIB-IVB; cm 3 25 x 1.8 Gy Planning aims 5 x 1.8 Gy Central placement of the block (applicator not considered) 3 cm 4 cm 5 cm EQD2 calculation (LQ model) Reporting: CTV HR, CTV IR & OAR Fenkell et al. IJROBP 2011
7 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy CTV HR 85 Gy 85 Gy Volume [cm 3 ] V at > 85 Gy V at > 60 Gy Norm. t. > 60 Gy Fenkell et al. IJROBP 2011
8 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy CTV HR 85 Gy 85 Gy Volume [cm 3 ] V at > 85 Gy V at > 60 Gy Norm. t. > 60 Gy Fenkell et al. IJROBP 2011
9 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy CTV HR 85 Gy 85 Gy CTV IR 60 Gy 60 Gy Volume [cm 3 ] V at > 85 Gy V at > 60 Gy Norm. t. > 60 Gy Fenkell et al. IJROBP 2011
10 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy CTV HR 85 Gy 85 Gy 60 Gy 60 Gy CTV IR CTV HR D90 aim Volume [cm 3 ] V at > 85 Gy V at > 60 Gy Norm. t. > 60 Gy CTV IR Fenkell et al. IJROBP 2011
11 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy CTV HR 85 Gy 85 Gy 60 Gy 60 Gy CTV IR CTV HR D90 aim Volume [cm 3 ] V at > 85 Gy V at > 60 Gy Norm. t. > 60 Gy CTV IR Fenkell et al. IJROBP 2011
12 Impact of 60 Gy Volume on Toxicity 60 Gy Volume (EBRT + BT) Barillot et al., IJROBP 2000;48:
13 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy 85 Gy 85 Gy 60 Gy 60 Gy OAR Aim D2cc = 81 Gy D2cc = 86 Gy Fenkell et al. IJROBP 2011
14 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy 85 Gy 85 Gy 60 Gy 60 Gy OAR Aim D2cc = 81 Gy D2cc = 86 Gy Fenkell et al. IJROBP 2011
15 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy 85 Gy 85 Gy 60 Gy 60 Gy OAR Aim D2cc = 81 Gy D2cc = 86 Gy Fenkell et al. IJROBP 2011
16 EBRT Boost: Planning Study I EBRT + BT EBRT+BT + PM boost EQD2 Contribution from PM boost Target volume aim: = 8.9 Gy 85 Gy 85 Gy 60 Gy 60 Gy OAR Aim D2cc = 81 Gy D2cc = 86 Gy In 4 out 6 pts: D2cc to at least one OAR increased by >50% of PM boost D Fenkell et al. IJROBP 2011
17 EBRT Boost: Planning Study II 23 patients Actual Pelvic IMRT Gy a 1.8 Gy Modelled MRI guided IC+IS BT 4x7 Gy; pl. aims Customized Boost 5 x 1.8 Gy Impact of PB V60 (cm 3 ) 593 (595.6) (81.5) <0.01 Mohamed et al. Brachytherapy 2014
18 Intracavitary Techniques EBRT? Boost needed... A Interstitial?
19 Intracavitary Techniques EBRT? Boost needed... A Interstitial?
20 Intracavitary - Interstitial techniques Insertion through perineal template Syed MUPIT Long needle tracks A target V Parallelism? Accuracy? N of needles Complications Syed AM, et al. Int J Radiat Oncol Biol Phys 2002 Syed AMN, et al. Endocurie Hypertherm Oncol 1986;2:1-13. Martinez A, et al. Int J Radiat Oncol Biol Phys 1984;10: Nag S, et al. Gynecol Oncol 1998;70:27-32.
21 Intracavitary - Interstitial techniques Insertion through the ring, parallel to tandem Needles loaded over 2 cm with 10% dwell weight of tandem Kirisits C, et al. Int J Radiat Oncol Biol Phys 2006;65(2): Dimopoulos J, et al. Int J Radiat Oncol Biol Phys 2006;66(1): mm additional coverage ( up to inner 2/3 of parametria )
22 Intracavitary - Interstitial techniques Insertion through the ring, parallel to tandem Feasibility study: 22 patients, 170 needles Prolongation of procedure: min No OAR perforation 2/170 needles could not be loaded (bending) 0.5 +/- 1mm 0.6 +/- 1mm Kirisits C, et al. Int J Radiat Oncol Biol Phys 2006;65(2): Dimopoulos J, et al. Int J Radiat Oncol Biol Phys 2006;66(1):83-90.
23 Intracavitary - Interstitial techniques Insertion through the ovoids, parallel to tandem Jürgenliemk-Schulz IM, et al. Radiother Oncol 2009;93: Nomden C, et al. Int J Radiat Oncol Biol Phys 2012;82(4):
24 Intracavitary - Interstitial techniques Parallel needles - Summary 1cm A A
25 Intracavitary - Interstitial techniques Parallel needles - Summary Large V +/- Unfavourable topography Template: Ring or Ovoids 1cm Short needle tracks A A Inst. Of Oncol. Ljubljana Good parallelism Accuracy Small V + Unfavourable topography Reproducibility N of needles Safe and feasible Inst. Of Oncol. Ljubljana Kirisits C, et al. Int J Radiat Oncol Biol Phys 2006;65(2): Dimopoulos J, et al. Int J Radiat Oncol Biol Phys 2006;66(1) Jürgenliemk-Schulz IM, et al. Radiother Oncol 2009;93: Nomden C, et al. Int J Radiat Oncol Biol Phys 2012;82(4):
26 Intracavitary - Interstitial techniques Parallel needles - Summary Target volume extending beyond reach of parallel needles? 1cm A A
27 Intracavitary - Interstitial techniques Parallel needles - Summary Target volume extending beyond reach of parallel needles? Addition of Oblique needles, ideally through vaginal template 1cm A A
28 Intracavitary - Interstitial techniques Parallel needles - Summary Target volume extending beyond reach of parallel needles? Addition of Oblique needles, ideally through vaginal template 1cm A A What might be the optimal applicator geometry?
29 Tumour Map from 264 patients (Lju, Aar, Vie) Petric P. University of Ljubljana 2017
30 Dose Distribution on Tumor Map without OAR constraints Petric P. University of Ljubljana 2017
31 Dose Distribution on Tumor Map without OAR constraints Petric P. University of Ljubljana 2017
32 Dose Distribution on Tumor Map without OAR constraints OPTIMAL GEOMETRY Petric P. University of Ljubljana 2017
33 Dose Distribution on Tumor Map with OAR constraints Residual Volume at Risk (RVR) Concept Transverse Sagittal Coronal A R 98% IDC cv L P A R L P RVR rectum < 70 Gy Petric P. University of Ljubljana 2017 Optimization objectives RVR bladder < 75 Gy RVR bowel < 70 Gy RVR sigmoid < 70 Gy
34 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR Iso-density Contour [%] V100 [%] No OAR 20 0 Petric P. University of Ljubljana Iso-density Contour [%]
35 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR OAR Iso-density Contour [%] V100 [%] OAR No OAR 20 0 Petric P. University of Ljubljana Iso-density Contour [%]
36 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR OAR Iso-density Contour [%] V100 [%] OAR No OAR 20 0 Petric P. University of Ljubljana Iso-density Contour [%]
![IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] 200 150 100 100 50 0 No OAR No OAR OAR 50 55 60 65 70 75 80 85 90 95 100 Iso-density](/docs-images/88/115505290/images/37-1.jpg "Contour [%] 81 95 98 V100 [%] 120 100 95 80 60 40 20 OAR No OAR No OAR Petric P.")
37 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR No OAR OAR Iso-density Contour [%] V100 [%] OAR No OAR No OAR Petric P. University of Ljubljana Iso-density Contour [%] 95 98
38 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR No OAR OAR OAR Iso-density Contour [%] 81 V100 [%] OAR No OAR No OAR OAR Petric P. University of Ljubljana Iso-density Contour [%]
39 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR No OAR OAR OAR Iso-density Contour [%] 81 V100 [%] OAR No OAR No OAR OAR Petric P. University of Ljubljana Iso-density Contour [%]
40 IC IS techniques Characteristic curves of Applicators 250 D90 [% of planning aim D] No OAR No OAR OAR OAR Parallel needles Iso-density Contour [%] Obl. 98 V100 [%] Petric P. University of Ljubljana Iso-density Contour [%] No OAR No OAR OAR OAR Parallel needles Obl
![IC IS techniques TRAK and Tumour Map Coverage 2,5 2 TRAK [cgy] 1,5 1 1.41 1.](/docs-images/88/115505290/images/41-0.jpg "22 0,5 0 50 60 70 80 90 100 Petric P.")
41 IC IS techniques TRAK and Tumour Map Coverage 2,5 2 TRAK [cgy] 1, , Petric P. University of Ljubljana 2017 RVR [%] 95 97
42 Intracavitary - Interstitial techniques SUMMARY: How well do these applicators perform? Applicator type Tumour map coverage IC only IC + IS PAR IC + IS PAR + IS OBL Petric P. University of Ljubljana 2017
43 Intracavitary - Interstitial techniques SUMMARY: How well do these applicators perform? Applicator type IC only Tumour map coverage % IC + IS PAR IC + IS PAR + IS OBL Petric P. University of Ljubljana 2017
44 Intracavitary - Interstitial techniques SUMMARY: How well do these applicators perform? Applicator type IC only IC + IS PAR Tumour map coverage % 95 % IC + IS PAR + IS OBL Petric P. University of Ljubljana 2017
45 Intracavitary - Interstitial techniques SUMMARY: How well do these applicators perform? 2% of Tumor Map Applicator type IC only IC + IS PAR IC + IS PAR + IS OBL Tumour map coverage % 95 % 98 % Petric P. University of Ljubljana 2017
46 Intracavitary - Interstitial techniques Commercially available solutions
47 Intracavitary - Interstitial techniques Personalized applicators 3D printing Petric P, et al.. In: Song W, et al. Eds. Taylor & Francis 2017; Figure: Hudej R, OI Ljubljana
48 Intracavitary - Interstitial techniques Personalized applicators 3D printing Lindegaard J, et al. Radiother Oncol 2015
49 Intracavitary - Interstitial techniques Personalized applicators 3D printing Lindegaard J, et al. Brachytherapy 2012
50 Special EBRT Techniques for PM boost Alternative to complex IC-IS boost technique? Applicator guided stereotactic IMRT Not replacement for IC-IS technique Alternative in 3/137 cases (2%) Assenholt MS, et al Brachytherapy 2014
51 Retro EMBRACE: impact of IC-IS; N=610 Centres performing IC-IS in > 20%: N = 300 IC/IS Group Centres performing IC-IS in 20%: N = 310 IC Group Local Control All CTV HR 30 cm 3 CTV HR < 30 cm 3 91% 86% 87% 80% 97% 93% Fokdal L, et al. Radiother Oncol 2016;120:
52 G2-5 Retro EMBRACE: impact of IC-IS; N=610 Centres performing IC-IS in > 20%: N = 300 IC/IS Group Centres performing IC-IS in 20%: N = 310 IC Group Morbidity Fokdal L, et al. Radiother Oncol 2016;120:
53 G3-5 Retro EMBRACE: impact of IC-IS; N=610 Centres performing IC-IS in > 20%: N = 300 IC/IS Group Centres performing IC-IS in 20%: N = 310 IC Group Morbidity Fokdal L, et al. Radiother Oncol 2016;120:
54 Vienna, May, 2018 Intracavitary + Interstitial Techniques Rationale Primoz Petric NCCCR, HMC, Doha
55 Vienna, November, 2017 Part II Emerging Technologies Primoz Petric NCCCR, HMC, Doha
56 Emerging technologies Static & Dynamic Shielding 3D printing Hyperthermia and brachytherapy Nanoparticle induced radiosensitization Nanoparticle based chemoradiation
57 Emerging technologies Static & Dynamic Shielding 3D printing Hyperthermia and brachytherapy Nanoparticle induced radiosensitization Nanoparticle based chemoradiation
58 Static shielding: Direction-modulated BT (DMBT) DMBT Conventional 75 plans compared: DMBT superior Discussion: D90: HR CTV D2cc: OAR Han DY, et al. Int J Radiat Oncol Biol Phys 2014;89;3:
59 Dynamic Rotating Shield Brachytherapy - D-RSBT Electronic brachytherapy source Shield: changing emission angles Liu Y, et al. Med Phys 2013 Emission window size profile Plans of 5 cases compared: D-RSBT vs. IC/IS BT 30 additional min. for D-RSBT: D90 improved for 20 Gy (EQD2) OAR doses +/- unchanged Liu Y, et al. Med Phys 2013 Adams QE, Xu J, Breitbach EK, et al. Med Phys 2014;41(5): Yang W, Kim Y, Wu X, et al.. Phys Med Biol 2013;58(11): Liu Y, et al.. Med Phys 2013;40(5): Dadkhah H, Flynn RT, Wu X et al. Med Phys 2015; 42: Liu Y, Flynn RT, Kim Y, Yang W, Wu X.. Med Phys 2013;40(12):12703 Liu Y, Flynn RT, Kim Y, Wu X. Med Phys 2014;41(11):111709
60 Static & Dynamic Shielding Less invasive alternative to IC/IS BT? CAUTION.. IC/IS Fundamentally different D distribution then with IC/IS BT TRAK V150, V200 D heterogeneity Emission angle Set-up errors? IC / IS BT: excellent results! Clinical impact? Combined IC / I S & Rotational Dynamic Shielding BT?
61 Emerging technologies Static & Dynamic Shielding 3D printing Hyperthermia and brachytherapy Nanoparticle induced radiosensitization Nanoparticle based chemoradiation
62 3D printing technology (IC or IC/IS) Classic Moulage technique Lindegaard J, et al. Radiother Oncol 2016 Courtesy: Hudej R, Institute of Oncology Ljubljana
63 Emerging technologies Static & Dynamic Shielding 3D printing Hyperthermia and brachytherapy Nanoparticle induced radiosensitization Nanoparticle based chemoradiation
64 Hyperthermia & Brachytherapy Dutch hyperthermia trial, 12 y FU Pelvic tumor control RT+HT RT Overall survival RT+HT RT From: Datta NR, et al. Cancer Treatment Reviews 2015 Years Toxicity: comparable Franckena M, et al. IJROBP 2008;70: Years Lutgens L, et al. Cochrane Database Syst Rev CD Complete remission Local recurrence Overall Survival Datta NR, et al. Cancer Treatment Reviews 2015;41: Mallory M, et al. Critical Rev in Oncol / Hematol 2016;97: Warrel G, et al. Med Phys. 2015;42(6):3709. Chen X, et al. Int J Hyperthermia. 2010;(1): Lutgens L, et al. Cochrane Database Syst Rev CD Franckena M, et al. IJROBP 2008;70: Franckena M, et al. IJROBP 2009;73: Franckena M, et al. Eur J Cancer 2009;45:
65 Hyperthermia & Brachytherapy Catheter based ultrasound applicators for integrated hyperthermia Sectored transducers Diederich CJ, er al. Med Phys 2014 Wootton JH, et al. Med Phys Diederich CJ, er al. Med Phys 2014 Spatial control of heating
66 Hyperthermia & Brachytherapy Catheter based ultrasound applicators for integrated hyperthermia Unsectored tandem: 360 Bisectored tandem: 2 x 180 Spatial control of heating Wootton JH, et al. Med Phys. 2011;38(2): Tandem + interstitial Pilot studies (cervix, prostate): feasible Diederich CJ, er al. Med Phys 2014 Further clinical studies needed
67 Emerging technologies Static & Dynamic Shielding 3D printing Hyperthermia and brachytherapy Nanoparticle induced radiosensitization Nanoparticle based chemoradiation
68 Nanoparticle induced radiosensitization Radiation induced photoelectrons from GNP DEF of > 20% at 5 mm from BT source Sinha N, et al. IJROBP 2014
69 Nanoparticle - based local chemoradiation Kumar R, Belz J, Markovic S, et al. Nanoparticle-based brachytherapy spacers for delivery of localized combined chemoradiation therapy. IJROBP 2015;91(2): Cormack RA, Sridhar S, Suh WW, et al. Biological in situ dose painting for image-guided radiation therapy using drug-loaded implantable devices. IJROBP 2010;76:
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