Radiotherapy: from Planning to Delivery. D. Genovesi Istituto Radioterapia Oncologica CHIETI
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1 Radiotherapy: from Planning to Delivery D. Genovesi Istituto Radioterapia Oncologica CHIETI
2 Radiotherapy: from Planning to Delivery TOPICS 1. Total Dose Prescription 2. Prescription & Contouring of Volumes 3. Technique of Radiation Therapy 4. Dose Constraints to Organ at Risks 5. Quality Assurance
3 1. Dose Prescription! Adjuvant setting: Gy (1.8 Gy/die)! Neoadjuvant setting: 45 Gy (1.8) CTV/T+N 50.4 (1.8) CTV/T! Definitive setting: Gy (1.8) CTV/T+N 54 Gy (1.8) CTV/T! Higher Doses ( 60 Gy): - No increased efficacy/ Tox - Clinical Trials only - Promising challenges: IMRT; Proton Therapy Huguet F. IJROBP 2012! SBRT alone: - Clinical studies - Single fraction Gy Gy in 3 fractions/gtv! SBRT boost: - Clinical studies/adapted to previous ERT! IORT: - Clinical studies/single fraction Gy
4 2. Prescription & Contouring of Volumes Prophylactic Nodal RT (ENI) Local failure = Predictor of Survival Vs. Selective Involved Nodal RT Why ENI?! High frequency of Lymphatic spread (60-80%)???! High rate of local and nodal failure (up to 75%)! LR in RT-CT with ENI vs. NO ENI: 0-13% vs. 25% Van der Geld YG. IJROBP 2008; Huguet F. IJROBP 2012; Caravatta L. Rad Oncol Turrini O. Oncology 2009; Varadhachary GR. J. Clin Oncol 2008
5 2. Prescription & Contouring of Volumes Methodology: a Stepwise Process Lymph nodal areas: patterns of LFN+ 18 pathologic reports/5954 resectable pancreatic cancer
6 2. Prescription & Contouring of Volume Preoperative/Definitive setting Radiat Oncol 2012 Cut-off Value to consider LFN at risk: 3%
7 2. Prescription & Contouring of Volumes Preoperative/Definitive setting! Abdominal blood vessels (ROIs for LFN delineation) Be Careful!!!!!!!!!!! Artery plus 10 mm to include soft tissue with lymphatic and neural plexus, except normal tissue (e.g. vertebral body): to cover 94% of nodes! Anatomical structures (ROIs for LFN delineation)! Contouring on CT planning with contrast/fusion! Cooperation Radiologist/Radiation Oncologist
8 Anatomic. ROIs ROIs LFN ROIs areas + 10 mm Delineate vascular anatomical ROI s ROI s: Ao Tumor = Aorta and positive Nodes CHA = Common Hepatic Artery Pyl = Pylorus; CT = Celiac Trunk GdA 1st D = Gastroduodenal first part of Duodenum; Artery IPdA = Inf. Pancreaticoduod.Artery; IVC 2nd = D Inferior = second Vena part Cava; of Duodenum JA = Jejunal Artery; CBD = Common Bile Duct MCA = Medial Colic Artery PV Pb = Pancreatic Portal Vein body; SMA Ph = Pancreatic = Superior Mesenteric head; Artery SMV Pt = Pancreatic = Superior tail; Mesenteric Vein SpV Splenic Vein Pdia = pillar of the diaphragm
9 CTV/N H E A D P A N C R E A S CTV/N B O D Y - T A I L
10 CTV/T: GTV cm EUS CT MRI CT PET Portal Vein Pancreas VMS Laparoscopy/ Laparotomy
11 2. Prescription & Contouring of Volumes Post-operative/Adjuvant setting! Complicated Abdomen Anatomy (Whipple procedure) Prescription:! Lymph node according to patterns of spread Sun W. Radiat Oncol 2010! Anastomoses! Tumor Bed
12 2. Prescription & Contouring of Volumes Post-operative/Adjuvant setting Methodology: a Stepwise Process
13 2. Prescription & Contouring of Volumes Post-operative/Adjuvant setting Identify Anatomic ROIs easily distinguished on Post-op Abdominal Imaging! Vascular structures cm in all directions - Celiac axis (to cover celiac nodes) - Superior Mesenteric Artery (to cover peripancreatic and SMA) - Portal Vein (porta hepatis nodes + choledochojejunostomy) - Aorta (paraortic, interaortocaval and paracaval nodes)! Anatomic ROIs: e.g. liver, spleen, colon! Anastomoses: Pancreaticojejunostomy (PJ) cm Pancreaticogastrostomy (PG): NO for Tox! Tumor Bed: Surgical Clips; NO CT preop image fusion different anatomy, set-up, respiration
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15 2. Prescription & Contouring of Volumes Post-operative/Adjuvant setting Target Volumes Head Body-Tail GTV CTV/T Tumor bed (clips; imaging pre-postop with contrast) or any residual disease; Anastomoses GTV cm in all directions CTV/N Goodman KA. IJROBP Lee NY. & Lu JJ. Target Volume Delineation and Field Setup ; Springer 2013
16 2. Prescription & Contouring of Volumes Palliative setting
17 2. Prescription & Contouring of Volumes CTV-PTV expansion! cm: anterior, posterior and lateral direction! 2 3 cm: cranio-caudal directions! these margins can be reduced with respiration-gated RT 12 mm CC; 7 mm LL; 5 mm Post! Individualized Margins for each Center: RECOMMENDED!!!
18 2. Prescription & Contouring of Volumes Organ at Risks (OARs) Duodeno Cuore Lee NY. & Lu JJ. Target Volume Delineation and Field Setup ; Springer 2013
19 Huguet F. IJROBP Technique of Radiation Therapy! 3D-CRT & IMRT are recommended techniques! Dose-variability inside PTV: ± 5%! SBRT: Clinical Studies
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26 4. Dose Constraints to OARs Duodeno 50% <30 Cuore V20 < 30%; V30 < 20%; 70% < 15 Gy
27 5. Quality Assurance (QA) QA is mandatory! Accuracy of Contouring! Definition of PTV (Margins)! Dose homogeneity! Respect of Dose Constraints to OARs! Beams arrangement! Dose delivered! Accuracy of Delivery Huguet F. IJROBP 2012
28 The Critical Importance of a Method for determining and correcting errors!!!! Simulaz Misura 1 Misura 2 Misura 3 Misura 4 Misura 5 Misura 6 Paziente 1 OSSERVATORE A OSSERVATORE B ARL ASI LAP LSI R ARL ASI LAP LSI R t s mandatory to perform a quantitative analysis f interfx shifts at least one time for each patology nd when you introduce treatment variables!!! To define, control and reduce your PTV margins
29 Online corrections of variations: IGRT formalities ACS Use of daily On-Board Imaging reduced uncertainty in amount of dose delivered Potential improvement in local control Optic Systems Gating Potential reduction in treatment toxicity Fiducial Markers kv CB-CT CT on-rail Tomotherapy
30 5. Quality Assurance (QA) Per Protocol Acceptable minor deviation Unacceptable
31 2013 Corso Itinerante AIRO La Radioterapia nel Carcinoma del Pancreas: Indicazioni Cliniche e Criteri Guida di Trattamento Padova 10 Maggio 2013 Chieti 14 Giugno 2013 Rionero in Vulture 20 Settembre 2013 Gastro-Intestinal AIRO Working Group
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