art for cervical cancer: dosimetry and technical...
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ART for Cervical Cancer:
Dosimetry and Technical Aspects
D.A. Jaffray, Ph.D.
Radiation Therapy Physics
Princess Margaret Cancer Centre/Techna/Ontario Cancer Institute
Professor
Departments of Radiation Oncology and Medical Biophysics
University of Toronto
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AAPM’13
Acknowledgements Princess Margaret Cancer Centre
J. Stewart, K.K. Brock, Y.-B. Cho, A. Fyles, M. Milosevic, K. Lim,
H. Alasti, M. Islam, S. Foxcroft, R. Dahdal, A. Simeneov,
M. Carlone, T. Stanescu, S. Breen, M. Gospodarowicz
RaySearch Laboratories – A. Lundin, H. Rehbinder, J. Lof
IMRIS - M. Dahan, J. Winters, D. Graves, B. Guyot, L. Petropoulus
Varian - M. Sweitzer
Funding: Canadian Foundation for Innovation, CIHR, OICR
Fidani Chair in Radiation Physics
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Background – EBRT+CT
Increased progression-free survival.
Reduced local and distant recurrence.
Acute toxicity increased.
Late toxicities?
Green, et al., Cochrane Review 2005:CD002225
Kirwan, et al., Radiotherapy & Oncology 2003;68:217-226
+
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Background - IMRT
Four-Field Box
Rectum
Bladder
Nodal CTV
Tumour CTV
IMRT
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MR-based Motion Assessment in Ca Cervix
• Inter- and Intrafractional Movement of the Uterus and
Cervix in Patients with Cervix Cancer Receiving
Radiotherapy: An MRI-Based Point-of-Interest (POI)
Analysis
• Patients treated with radical chemo-radiotherapy imaged
with serial Cine-MRI scans
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Background – Morphological Changes over Tx
Pre-Tx 8 Gy 20 Gy
28 Gy 38 Gy 48 Gy
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Combined
Motion
and
Response
7 July
21 July
14 July
5 Aug
30 Minute
Acquisition
Cycle
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AAPM’13
Challenges in IMRT for Cervix Cancer
Target Identification
• MR vs CT
• Nodal targets
• Online image quality
Organ motion
• Influence of
– Bladder filling
– Rectal filling
– Normal uterus position
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Week 1 Week 2 Week 3 Week 4 Week 5
Background – Interfraction Motion
ORBIT Workstation
Planning
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Week 1
Background – Interfraction Motion
ORBIT Workstation
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Week 2
Background – Interfraction Motion
ORBIT Workstation
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Week 3
Background – Interfraction Motion
ORBIT Workstation
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Week 4
Background – Interfraction Motion
ORBIT Workstation
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Week 5
Background – Interfraction Motion
ORBIT Workstation
Rectum-
Sigmoid
Tumour
Cervix Uterus
Bladder
Background – Interfraction Motion
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Aim
Use weekly imaging feedback to dosimetrically and volumetrically monitor treatment progress and adapt to ensure clinical goals are met.
Plan A
MRI
MRI
Plan A
Plan B
MRI Plan B
MRI Plan B
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0 5 10 15 20 25 0
10
20
30
40
50
To
tal Ta
rget
Dose
(G
y)
Fraction
Aim
Replan
Weekly
Imaging
Use weekly imaging feedback to dosimetrically and volumetrically monitor treatment progress and adapt to ensure clinical goals are met.
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Aim
Replan to further
OAR dose sparing
Weekly
Imaging
0 5 10 15 20 25 0%
100%
Ta
rget
Volu
me
Fraction
Use weekly imaging feedback to dosimetrically and volumetrically monitor treatment progress and adapt to ensure clinical goals are met.
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Methods
• 33 patients with stage IB-IVA cervix cancer
• Target volumes (GTV and CTV) and OARs (rectum, sigmoid, bladder, and bowel) contoured on fused MR-CT baseline image and subsequent weekly MR scans
• Primary CTV (pCTV) defined as union of:
– GTV
– Cervix
– Parametria
– 2 cm of uterus superior to GTV
– 2 cm of upper vagina inferior to GTV
Rectum
GTV Bowel Sigmoid
Bladder CTV
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Methods – Deformable Registration
Planning (pre-treatment)
Week 1 Week 2 Week 3
Week 4 Week 5
Brock, et al., Medical Physics 2005;32:1647-1659.
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+
Methods – Dose Accumulation / ORBIT
Planned Dose
Accumulated Dose
Apply planned dose
at each fraction
Deform each fraction
to planning geometry
Accumulate across
all fractions
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Accumulated (where the dose was actually delivered)
Planning (where we planned the dose to go)
Methods - ORBIT
Difference Did we miss the target?
Were OARs compromised?
Cold spot in tumour Higher sigmoid dose
than planned
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Planning Scenarios
Planning Accumulate
IMRT w/ 3mm PTV margin Criteria: • D98% GTV > 50 Gy • D98% CTV > 49 Gy • D98% PTV > 47.5 Gy
25 Fractions
IMRT Plan Optimization Function
Initiate replan if weekly dose accumulation
triggers one of the following:
1) D98% GTV < 49 Gy or
D98% CTV < 47.5 Gy
2) CTV volume drops 100 cm3
Dose triggers
Volume trigger
Planned 1 No Replan 2 Assess Weekly 3
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Example Patient #1
Week 2 – without
Re-plan
Planned
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Automated Weekly Replan (Week 2)
Automated Weekly Replan (Week 2)
No Replan (Week 2)
No Replan (Week 2)
Results – Example of Improved Target Coverage
GTV CTV
Planned
Delivered
Planned No Replan Weekly Replan
GTV 50.1 47.4 50.2
CTV 49.1 46.5 49.1
Dose to 98% Volume (Gy)
Bladder
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5.6 cm
Example Patient #2
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Example Patient #2
GTV
CTV
Planned Week 4
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Example Patient #2
Week 4 / No Replan Week 4 / Replan to reduce dose to OARs
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Planned No Replan Assess Weekly45
46
47
48
49
50
51
Do
se
to
98
% V
olu
me
(G
y)
100%
98%
95%
Planned No Replan Assess Weekly45
46
47
48
49
50
51
Do
se
to
98
% V
olu
me
(G
y)
100%
98%
95%
Results – Target Coverage
GTV CTV
8
(24%)
2
(6%)
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Results – Replanning Workload vs Week
1 2 3 4 50
2
4
6
8
10
12
14
Num
ber
of
Rep
lans
MRI / Week
Target dosimetry (24 replans)
CTV regression (12 replans)
Both (1 replan)
n = 33 n = 14
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Results – Distribution of Triggered Plans
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Limitations of the Study
• MRI scans obtained each week expanded to represent
each fraction
– For example, scan 1 at fraction 1 assumed to be
representative of fractions 1-5
• Perfect bone-bone matching assumed at each fraction
• Deformable registration algorithm MORFEUS
currently undergoing accuracy validation for cervix
(validated in lung, prostate and liver)
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Summary of Adaptive Planning Study
• A 3 mm PTV margin for cervix cancer is valid
for a subset of patient (76%), but we don’t
know who they are until we have imaged them
for ~2 weeks.
• Opportunity to reduce dose to normal tissues
with this strategy while assuring target
coverage.
• Dosimetric triggers of target coverage do not
maximize the normal tissue dose reduction.
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The Princess MRgRT Facility
Tri-use Facility based on a single 1.5T magnet and state-of-the-art delivery
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MRgRT Pelvis Configuration
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Prostate
MRgRT Pelvis Coil: Volunteer Images
1.5 T, T2 weighted images of two volunteers.
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MRgRT Pelvis Coil: Volunteer Images
Prostate
1.5 T, T2 weighted images of two volunteers.
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MRgRT External Beam Workflow
IGRT-guided pre-localization
of MR Imaging FOV
Confirmation of delivery
viability
Reference CBCT for MR-
guidance
Robotic control of MR, table
and Shielding System
Linear motion of magnet
over patient.
RT present for movement.
Pre-stored MR configuration
from MR-simulation Stage
Critical time specification
(<90s) from end of imaging
to beam-on.
Image processing (distortion
correction, calibration) and
planning (adaptation).
Generation of couch or
machine adjustment.
*MR can begin image within 5s of stopping.
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Summary
• Developed an experience in the use of MR for adaptive RT of the cervix using retrospective analysis.
• Anticipate significant advantages wrt normal tissue dose reduction with reasonable workload using weekly MR imaging.
• Building a system that will enable state-of-the-art MR imaging for adaptation.
• Exciting prospect for adaptive workflows that will assure coverage and reduce normal tissue dose.