IMRT IGRT SBRT Advances in the Treatment Planning and Delivery of Radiotherapy 2nd, revised and extended edition

IMRT IGRT SBRT Advances in the Treatment Planning and Delivery of Radiotherapy 2nd, revised and extended edition

Frontiers of Radiation Therapy and Oncology Vol. 43 Series Editors J.L. Meyer San Francisco, Calif. W. Hinkelbein Berlin

IMRT IGRT SBRT Advances in the Treatment Planning and Delivery of Radiotherapy 2nd, revised and extended edition Volume Editor John L. Meyer San Francisco, Calif. Advisory Editors L.A. Dawson Toronto, Ont. B.D. Kavanagh Aurora, Colo. J.A. Purdy Sacramento, Calif. R. Timmerman Dallas, Tex. 211 figures, 175 in color, and 41 tables, online supplementary material, 2011 Basel Freiburg Paris London New York New Delhi Bangkok Beijing Tokyo Kuala Lumpur Singapore Sydney

Frontiers of Radiation Therapy and Oncology Founded 1968 by J.M. Vaeth, San Francisco, Calif. John L. Meyer, MD, FASTRO Department of Radiation Oncology Saint Francis Memorial Hospital San Francisco, Calif., USA Library of Congress Cataloging-in-Publication Data IMRT, IGRT, SBRT: advances in the treatment planning and delivery of radiotherapy / volume editor, John L. Meyer; advisory editors, L.A. Dawson... [et al.]. -- 2nd, rev. and extended ed. p. ; cm. -- (Frontiers of radiation therapy and oncology, ISSN 0071 9676; v. 43) Includes bibliographical references and indexes. ISBN 978 3 8055 9680 0 (hard cover: alk. paper) -- ISBN 978 3 8055 9681 7 (e-isbn) 1. Cancer -- Radiotherapy. 2. Radiotherapy. I. Meyer, John, 1949 II. Series: Frontiers of radiation therapy and oncology; v. 43. 0071 9676 [DNLM: 1. Radiotherapy, Computer-Assisted--Methods. W3 FR935 v.43 2011 / WN 250.5.R2] RC271.R3I435 2011 616.99 40642--dc22 2011000684 Bibliographic Indices. This publication is listed in bibliographic services, including Current Contents and PubMed/MEDLINE. Illustrations. The authors and the publisher have made every effort to obtain permission for all copyright-protected material. Any omissions are entirely unintentional. The publisher would be pleased to hear from anyone whose rights unwittingly have been infringed. Disclaimer. The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publisher and the editor(s). The appearance of advertisements in the book is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Drug Dosage. The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Copyright 2011 by S. Karger AG, P.O. Box, CH 4009 Basel (Switzerland) www.karger.com Printed in Switzerland on acid-free and non-aging paper (ISO 9706) by Reinhardt Druck, Basel ISSN 0071 9676 ISBN 978 3 8055 9680 0 e-isbn 978 3 8055 9681 7

Contents VIII Frequently Used Abbreviations IX Preface Meyer, J.L. (San Francisco, Calif.) Introduction 1 Advances in the Planning and Delivery of Radiotherapy: New Expectations, New Standards of Care Purdy, J.A. (Sacramento, Calif.) General Concepts and Methods 29 Advanced Technologies in the Radiotherapy Clinic: System Fundamentals Meyer, J.L. (San Francisco, Calif.); Sharpe, M.; Brock, K. (Toronto, Ont.); Deasy, J. (St. Louis, Mo.); Craig, T.; Moseley, D. (Toronto, Ont.); Alaly, J.; Zakaryan, K. (St. Louis, Mo.) Economic Perspectives 60 Controversies in the Adoption of New Healthcare Technologies Wallner, P.E. (Fort Myers, Fla.); Steinberg, M.L. (Los Angeles, Calif.); Konski, A.A. (Detroit, Mich.) I. IMRT and IGRT: Intensity-Modulated and Image-Guided Radiotherapy IMRT: Advances in Treatment Design and Delivery 80 Clinical Implementation of Intensity-Modulated Arc Therapy Shepard, D.M.; Cao, D. (Seattle, Wash.) V

IGRT: Advances in Targeting Therapy 99 4D Imaging and 4D Radiation Therapy: A New Era of Therapy Design and Delivery Low, D. (Los Angeles, Calif.) 118 Locating and Targeting Moving Tumors with Radiation Beams Keall, P. (Sydney, N.S.W.) Integrating IMRT and IGRT into Treatment Delivery 132 Technologies of Image Guidance and the Development of Advanced Linear Accelerator Systems for Radiotherapy Wu, V.W.C.; Law, M.Y.Y. (Hong Kong); Star-Lack, J. (Palo Alto, Calif.); Cheung, F.W.K. (Hong Kong); Ling, C.C. (New York, N.Y./Palo Alto, Calif./Hong Kong) 165 Helical Tomotherapy: Image-Guided and Adaptive Radiotherapy Kupelian, P. (Los Angeles, Calif.); Langen, K. (Orlando, Fla.) 181 The CyberKnife in Clinical Use: Current Roles, Future Expectations Dieterich, S.; Gibbs, I.C. (Stanford, Calif.) II. IMRT and IGRT Clinical Treatment Programs 196 Image Guidance and the New Practice of Radiotherapy: What to Know and Use from a Decade of Investigation Kim, J. (Toronto, Ont.); Meyer, J.L. (San Francisco, Calif.); Dawson, L.A. (Toronto, Ont.) Head and Neck Cancers 217 Intensity-Modulated and Image-Guided Radiation Therapy for Head and Neck Cancers Chu, K.P.-M.; Le, Q.-T. (Stanford, Calif.) 255 Delineating Neck Targets for Intensity-Modulated Radiation Therapy of Head and Neck Cancer David, M.B.; Eisbruch, A. (Ann Arbor, Mich.) Thoracic Cancers 271 Motion Management and Image Guidance for Thoracic Tumor Radiotherapy: Clinical Treatment Programs Loo, B.W., Jr. (Stanford, Calif.); Kavanagh, B.D. (Aurora, Colo.); Meyer, J.L. (San Francisco, Calif.) Breast Cancer 292 Intensity-Modulated Radiotherapy for Breast Cancer: Advances in Whole and Partial Breast Treatment White, J.R. (Milwaukee, Wisc.); Meyer, J.L. (San Francisco, Calif.) VI Contents

Abdominal Cancers 315 Image-Guided Radiotherapy Strategies in Upper Gastrointestinal Malignancies Swaminath, A.; Dawson, L.A. (Toronto, Ont.) Lymphomas 331 Radiotherapy Planning for the Lymphomas: Expanding Roles for Biologic Imaging Hoppe, R. (Stanford, Calif.) Prostate Cancer 344 Image-Guided, Adaptive Radiotherapy of Prostate Cancer: Toward New Standards of Radiotherapy Practice Kupelian, P. (Los Angeles, Calif.); Meyer, J.L. (San Francisco, Calif.) III. SBRT: Stereotactic Body Radiotherapy SBRT Advances 370 The Expanding Roles of Stereotactic Body Radiation Therapy and Oligofractionation: Toward a New Practice of Radiotherapy Kavanagh, B.D. (Aurora, Colo.); Timmerman, R. (Dallas, Tex.); Meyer, J.L. (San Francisco, Calif.) 382 Stereotactic Body Radiation Therapy: Normal Tissue and Tumor Control Effects with Large Dose per Fraction Timmerman, R.; Bastasch, M.; Saha, D.; Abdulrahman, R.; Hittson, W.; Story, M. (Dallas, Tex.) Thoracic Cancers 395 Stereotactic Body Radiation Therapy for Thoracic Cancers: Recommendations for Patient Selection, Setup and Therapy Timmerman, R.; Heinzerling, J.; Abdulrahman, R.; Choy, H. (Dallas, Tex.); Meyer, J.L. (San Francisco, Calif.) Gastrointestinal Cancers 412 Stereotactic Body Radiation Therapy for Gastrointestinal Malignancies Minn, A.Y.; Koong, A.C.; Chang, D.T. (Stanford, Calif.) Genitourinary Cancers 428 Stereotactic Body Radiotherapy for Prostate Cancer: Current Results of a Phase II Trial King, C. (Los Angeles, Calif.) Contents VII

IV. Proton Beam Radiotherapy Techniques and Technologies 440 Proton Therapy: Clinical Gains through Current and Future Treatment Programs Mohan, R. (Houston, Tex.); Bortfeld, T. (Boston, Mass.) Medical Applications and Advances 465 Proton Therapy in the Clinic DeLaney, T.F. (Boston, Mass.) 486 Author Index 487 Subject Index O S M Online supplementary material: www.karger.com/frato43_suppl Frequently Used Abbreviations 3DCRT CTV DVH EPID GTV IGRT IMRT kv MV PTV RTOG SBRT Three-dimensional conformal radiotherapy Clinical target volume Dose-volume histogram Electronic portal imaging device Gross tumor volume Image-guided radiotherapy Intensity-modulated radiotherapy Kilovoltage Megavoltage Planning target volume Radiation Therapy Oncology Group Stereotactic body radiotherapy VIII Contents

Preface This volume offers a guide to the techniques and technologies that can bring new, advanced radiotherapy capabilities into daily patient care. It is intended to be a readable and practical resource, presenting useful radiotherapy programs for clinical application, guidance on their efficient use and specific evidence for their selection from recent reports on clinical outcomes. The volume is divided into four sections. The first offers explanations and discussions of the technologies themselves and technical methods for their implementation. The second section brings these technologies into the radiation clinic with presentations by noted physicians at major centers who have broad experience with these new treatment approaches. In each chapter, the authors give specific guidelines for current clinical practice. The third section explores the use of these high-precision technologies in the rapidly expanding field of stereotactic body radiotherapy. The final section discusses the important advances in proton therapy, which is adding a new dimension to the range of available treatment technologies. This second edition takes a broad new vantage on the substantial changes that have recently occurred in the field of radiation oncology. For many cancer conditions, intensity-modulated, image-guided and stereotactic body treatment programs have become expected services of the modern, comprehensive radiotherapy clinic, and clear understanding of their use in now basic to practice. Despite their rapid adoption, many fundamental issues regarding their roles are still being defined at every step from tumor imaging and therapy planning to treatment delivery. Measures of clinical outcomes and their value based on cost/benefit analyses are just now being reported. Many new insights into their clinical indications, integration and efficient utilization are coming into focus, and their roles are redefining practice in new hypofractionated treatment programs. Further, the growing contributions of proton therapy add a new level of decision and treatment se- IX

lection for clinicians. Central to all of these issues are the current economics and practical allocations of our medical resources, which may increasingly define the utilization of these technologies. These developments, and their relative merits, are the focus of this volume. I have planned and developed the text based on presentations given at the 2009 San Francisco Radiation Oncology Conference, which was jointly sponsored by the Departments of Radiation Oncology of Stanford University, University of California at San Francisco, Saint Francis Memorial Hospital San Francisco and University of California at Davis. Drs. Richard Hoppe, Mack Roach III, James Purdy, Paul Keall and Jean Pouliot supported me in organizing the conference. I wish to thank each of them. Presentations have been expanded, updated, referenced and integrated for this volume, and several additional chapters were contributed to complete the scope of the text. Advances in radiologic imaging are the foundation of much of the current work explored in this text. Throughout the volume, examples of this are often presented in more than one format. In addition to the printed illustrations, a website (www. karger.com/frato43_suppl) allows the reader to view a number of the important figures in time-elapse videos. This is especially useful in understanding the work on tumor motion and image guidance. Other illustrations are also posted on this website for greater clarity and dynamic visualization, and the website is an essential part of these presentations overall. I wish to thank all of the authors for working with me on this text, especially Drs. James Purdy, Laura Dawson, Brian Kavanagh and Robert Timmerman for their excellent contributions and guidance. I wish to thank Dr. Catherine Burns for her expert assistance in the editing of the volume, and Mr. Josue Castellano for his expertise in organizing its illustrations and website materials. Finally I wish to thank Dr. Thomas Karger and the many associates of his fine publishing house. John L. Meyer, MD, FASTRO San Francisco, Calif., USA X Preface