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CyberKnife® VOLO™ Experience at Penn Medicine LGH

Hong F. Xiang, PhD, DABR

Penn Medicine Lancaster General Health

AERO™ Academy at ASTRO, September 15, 2019

Disclosure and Disclaimer

• An honorarium is provided by Accuray for this presentation• The views expressed in this presentation are those of the presenter

and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products, or services contained in this presentation is intended or should be inferred.

• Accuray and Penn Medicine LGH have a research agreement in place.

Outline

End Points of Using VOLO™ Optimization for CyberKnife® SRS/SBRT

1. Faster Optimization to Reach Optimal Plans?

2. Shorter SRS/SBRT Treatment Delivery Time?

3. Tangible Impact to Patient Access to SRS/SBRT?

Measure of Improvements – SRS/SBRT Cases:

Brain SRS/SRT: 3 Cases: 2 SRS and a IMRT

Spine SRS/SBRT: 2 SRS Cases per RTOG 06311 Case Re-Tx Post Conv. EBRT

Prostate SBRT: 3 Cases, RTOG 0938 & PACE Trial

Lung SBRT: 3 Cases per RTOG 0813

Liver SBRT: 1 Case Per RTOG 1112

VOLO™ Experience at Penn Medicine LGH

Methods of Comparison VOLO™ vs. SEQ Optimization

1. Same Goals for Target Coverage and OAR DVH Constraints

2. Optimization Time = Optimization + Final Dose Calc (Hi-Res)

3. Estimated Treatment Delivery Time: Imaging Time ExcludedInit. Pt. setup Excluded

VOLO™ Experience at Penn Medicine LGH

Brain SRS/SRT Cases

Brain Met, Rx 18 Gy x1Optic Nerve & Chiasm

Meningioma, Rx 12 Gy x1Irregular Tumor Shape

Brain Tumor Rx 1.8 Gy x30In Touch with Optic Chiasm

1.2. 3.

Brain SRS/SRT Plan & Delivery VOLO™ FIXOptimization

SEQ FIXOptimization

VOLO™-SEQSEQ

1.

2.

3.

Total Plan MU 12125 12544 -3.3%

Optimization (min) 7.8 12.7 -38.6%

Est. Delivery (min) 50 52 0.0%

Brain Met, Rx 18 Gy x1Optic Nerve & Chiasm

Meningioma, Rx 12 Gy x1Irregular Tumor Shape

Brain Tumor 1.8 Gy x30in Touch w. Optic Chiasm

Total Plan MU 6676 14500 -54.0%

Optimization (min) 14.1 28.0 -49.6%

Est. Delivery (min) 31 49 -36.7%

Total Plan MU 23292 26993 -13.7%

Optimization (min) 8.6 15.0 -42.7%

Est. Delivery (min) 15 34 -55.9%

Brain SRS/SRT CasesVOLO™ Experience at Penn Medicine LGH

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35

0 1 2 3 4

Optimization Time (min)

VOLO SEQ

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15

25

35

45

55

65

0 1 2 3 4

Est. Tx Delivery Time (min)

VOLO SEQ

Spine SRS/SBRT Cases

1. A Spine SRS for T-Spine T2 18 Gy x 1, per RTOG 0631

2. A Spine SRS for L-Spine L2 18 Gy x 1, per RTOG 0631

3. A Spine SBRT for Re-irradiation L2-L3, 6 Gy x5 (30Gy)(Prior EBRT, Spine T10-L3, 3 Gy x10 = 30Gy)

VOLO™ Experience at Penn Medicine LGH

Spine SRS/SRT Cases

SRS Spine T2, 18Gy x1, per RTOG 06311. 2. SRS Spine L2, 18Gy x1, per RTOG 0631

Spine SRS/SRT CasesRe-irradiation L2-L3, SBRT 6Gy x5

Prior EBRT, T10-L3, 3Gy x103.

VOLO™ Experience at Penn Medicine LGH

Spine SRS/SRT Plan & Delivery VOLO™ FIXOptimization

SEQ FIXOptimization

VOLO™-SEQSEQ

1.

2.

3.

Total Plan MU 16849 46377 -63.7%

Optimization (min) 10.6 20.8 -49.0%

Est. Delivery (min) 36 72 -50.0%

Total Plan MU 14761 40578 -63.6%

Optimization (min) 10.6 11.0 -3.6%

Est. Delivery (min) 42 66 -36.4%

Total Plan MU 32122 35008 -8.2%

Optimization (min) 25.0 49.8 -49.8%

Est. Delivery (min) 32 41 -22.0%

Spine T2, 18Gy x1per RTOG 0631

Spine L2, 18Gy x1per RTOG 0631

Re-irradiation L2-L3 SBRT 6Gy x5, w. Prior EBRT T10-L3, 3Gyx10

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Optimization Time (min)

VOLO SEQ

Spine SRS/SBRT CasesVOLO™ Experience at Penn Medicine LGH

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80

0 1 2 3 4

Est. Tx Delivery Time (min)

VOLO SEQ

SBRT for Re-Irradiation: L2-L3, 6 Gy x 5after a Prior EBRT T10-L3, 3 Gy x10

Key question for this case:

“How much additional dose can the spinal cord and cauda equina take?”

Tools & Evidence-based Guidelines needed:

1. A fast optimization tool for turn out plan timely for reviews? VOLO™

2. A capable EVAL tool for image fusion, BED, dose accumulation? MIM

3. Evidence-based guidelines: Safe re-irradiating spinal cord? Sahgal, et al.IJROBP 2012

Faster Optimization for SBRT Spine Re-Irradiation

VOLO™ Optimization is approximately 50% faster than the SEQ Optimization

For this plan,

Evaluating Dose Tolerance for Re-Irradiating Cord & Cauda in MIM Software

+ =

Spine T1-L3, EBRT 300 cGy x 10Varian/Eclipse

L-Spine RE-Tx SBRT 600 cGy x 5CyberKnife®/Precision®

“Apples” “Oranges” EQD2 (Gy2/2)vs.

Composite Plan Dose 2-Gy per fx Equivalent

1. Max thecal sac dose in total nBED ≤ 70 Gy EQD2 [ ? ]

2. A SBRT (plan) thecal sac max dose ≤ 25 Gy EQD2 [ ? ]

3. Ratio of nBED (thecal sac): SBRT/(SBRT+EBRT) ≤ 0.5 [ ? ]

4. A minimum time interval to re-irradiation ≥ 5 months [ ? ]

This CaseGuidelines

Evidence-based guidelines on Tolerance for Re-irradiation of Spinal Cord in SBRT after Conv. EBRT

Sahgal, et al. IJROBP, 82(1): 107-116, 2012

1. Max thecal sac dose in total nBED ≤ 70 Gy EQD2 56.5 Gy EQD2

2. A SBRT (plan) thecal sac max dose ≤ 25 Gy EQD2 23.8 Gy EQD2

3. Ratio of nBED (thecal sac): SBRT/(SBRT+EBRT) ≤ 0.5 0.42

4. A minimum time interval to re-irradiation ≥ 5 months Yes ≥ 5 months

Evidence-based guidelines on Tolerance for Re-irradiation of Spinal Cord in SBRT after Conv. EBRT

Sahgal, et al. IJROBP, 82(1): 107-116, 2012

This CaseGuidelines

Prostate SBRT: 3 Cases

1. Low Risk Prostate Case, CTV = Prostate, per RTOG 0938Homogeneous Dose 7.25 Gy x5 to PTV

2. Low Risk Prostate Case, CTV = Prostate, per PACE Trial 36.25/5Fx GY PTV(95%), 40 Gy/5Fx Prostate(95%)

3. Intermediate Risk, CTV = Prostate + prox. SVs, per PACE36.25/5Fx Gy PTV (95%), 40 Gy/5Fx Prostate (95%)

VOLO™ Experience at Penn Medicine LGH

Low Risk Prostate, 36.25 Gy toPTV, 40 Gy to Prostate, per PACE1. 2. 3.Low Risk Prostate, 36.25 Gy to

PTV, per RTOG 0938Intermediate Risk, 36.25 Gy Prostate+SVs

40 Gy to Prostate, per PACE Trial

Prostate SBRT Plan & Delivery VOLO™ MLCOptimization

SEQ MLCOptimization

VOLO™-SEQSEQ

1.

2.

3.

Total Plan MU 14474 31713 -54.4%

Optimization (min) 5.5 9.0 -38.9%

Est. Delivery (min) 12 25 -52.0%

Total Plan MU 14077 35514 -60.4%

Optimization (min) 7.1 13.0 -45.4%

Est. Delivery (min) 12 27 -55.6%

Total Plan MU 14067 34647 -59.0%

Optimization (min) 9.9 12.6 -21.4%

Est. Delivery (min) 13 25 -48.0%

Low Risk PTV 7.25Gyx5per RTOG 0938

Low Risk PTV 7.25Gyx540 Gy Prostate per

PACE Trial

Intermediate Risk(Prostate + Prox.SVs) 7.25Gyx5 PTV, 40 GyProstate, PACE Trial

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50

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Est. Tx Delivery Time (min)

VOLO SEQ

2.5

4.5

6.5

8.5

10.5

12.5

14.5

16.5

0 1 2 3 4

Optimization Time (min)

VOLO SEQ

Prostate SBRT CasesVOLO™ Experience at Penn Medicine LGH

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Est. Tx Delivery Time (min)

VOLO™ Experience at Penn Medicine LGH

Boston, MA G4 FIX/SEQ: 35-50 min

Penn/LGH, PA M6 MLC/SEQ: 20-30 min

Penn/LGH, PA M6 MLC/VOLO: 10-15 min

CyberKnife® Prostate SBRT: 2011-2019

Lung SBRT: 3 Cases

1. Lung SBRT Case, RUL, 1000 cGy x5, per RTOG 0813

2. Lung SBRT, Rt Lung, Sup 2 Lesions, 1000x5/RTOG 0813

3. Lung SBRT, Rt Lung, Inf 2 Lesions, 1000x5/RTOG 0813

VOLO™ Experience at Penn Medicine LGH

Lung SBRT: 3 Cases VOLO™ Experience at Penn Medicine LGH

1.

2.

3.

RUL 10 Gy x 5per RTOG 0813

RUL 2 GTV 10 Gy x 5per RTOG 0813

R Lung 2 GTVs 10Gyx5per RTOG 0813

Lung SBRT Plan & Delivery VOLO™ MLCOptimization

SEQ MLCOptimization

VOLO™-SEQSEQ

1.

2.

3.

Total Plan MU 14631 31632 -53.7%

Optimization (min) 6.2 11.0 -43.6%

Est. Delivery (min) 16 35 -54.3%

Total Plan MU 19193 31355 -10.1%

Optimization (min) 13.5 25.3 -46.6%

Est. Delivery (min) 16 30 -46.7%

Total Plan MU 32122 35008 -8.2%

Optimization (min) 25.0 49.8 -49.8%

Est. Delivery (min) 32 41 -22.0%

RUL 10 Gy x 5per RTOG 0813

RLL 10 Gy x 5per RTOG 0813

A Liver SBRT Case per RTOG 1112

Liver SBRT Plan & Delivery VOLO™ MLCOptimization

SEQ MLCOptimization

VOLO™-SEQSEQ

Liver PTV 5.0 Gy x 5per RTOG 1112

Total Plan MU 25528 31849 -19.8%

Optimization (min) 11.9 29.6 -59.8%

Est. Delivery (min) 19 44 -56.8%

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VOLO SEQ

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VOLO SEQ

Lung & Liver SBRT CasesVOLO™ Experience at Penn Medicine LGH

Impact on Patient Access to CyberKnife® SRS/SBRTVOLO™ may not be the only factor,

but certainly A HELP for us to take higher volumes

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Series1 Series2

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2-year-average before VOLO™ Current year since VOLO™

Conclusions

1. Faster Optimization to Reach Optimal Plans? On ave. reduce by -43.6%

2. Shorter SRS/SBRT Treatment Delivery Time? On ave. reduce by -56.8%

3. Tangible Impact to Patient Access to SRS/SBRT? Tx vol. is up by ave 150%

VOLO™ Optimization for CyberKnife® SRS/SBRT