authored by: toby shutters, b.s. rt(r) (t) indiana university school of medicine medical dosimetry...
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Dosimetric Evaluation ofPlanning Techniques in Lung SBRT
Authored by:Toby Shutters, B.S. RT(R) (T)
Indiana University School of MedicineMedical Dosimetry Graduate Certificate Program
Indianapolis, Indiana
Co-Authored by:
Jeannie Jimerson, M.S. RT (T), CMDRichard Roudebush VA Medical Center
SBRT
Hypofractionation
High Conformality
Steep Dose Gradients
Stereotactic Body Frame
http://www.erasmusmc.nl/radiotherapie/patientenzorg/behandelmethoden/uitwendigebestraling/128828/314368/
Non-small Cell Lung Cancers (NSCLC)
Surgical Options
Lobectomy
Wedge resection or segmentectomy
Comorbidities
RadiationConventional External
BeamSBRT
Small Daily Fractions
Total Fractions 27 to 33
5 year survival rate of 10 to 30%
Large Daily Fractions
Total Fractions 1 to 5
3 year local control rates of up to 98%
Increases in late toxicities
LocationDosimetrically challenging
Tumors adjacent to the chest wall areaDeliver high conformal dosesMinimize critical structure doses
Late toxicitiesChest wall painRib fractures
ToxicitiesNatonal Institute Common Terminology
Criteria for Adverse EventsGrade 1
Mild painGrade 2
Moderate painGrade 3
Severe painGrade 4
Disabling pain
Doses
Andolino et al
10% risk of grade 1 or greater at 30 Gy with 15cc’s
30% risk at 30 Gy with 40 cc’s
50 Gy greater incidence of rib fracture or chest wall pain
Dunlap et al
30 Gy in 3-5 fractions should be less than 30cc’s
50 Gy greater incidence of rib fracture or chest wall pain
Dosimetric EvaluationThis study retrospectively analyzed three
planning techniques to determine if a there was a dosimetric advantage utilizing noncoplanar geometry. All five patients had adjacent or invasive chest wall lesions. The plans were evaluated using the Conformality Index from RTOG 0813 and 0915. Chest wall and rib volumes were examined at V30Gy, V45Gy, and V50Gy.
Methods and Materials5 patients with adjacent chest wall tumors
Eclipse Version 8.0
Elekta Bodyframe
GTV’s and PTV’s
OAR’s through RTOG protocols
Evaluation of dose
Methods and Materials, continuedTwo sets of blocks
Modifications to blocks and weighting of PTV
95% of the PTV volume covered by prescription
Most common isodose 80%
Three Planning TechniquesCoplanar (COP)
No couch rotations
Mixed Planar (MP)Some couch rotations, some not
Non-coplanar (NCP)All couch rotations
Three Planning Techniques: COPField Label Gantry Angle Couch Rotation
AP 0 0
RAO 333 333 0
RAO 305 305 0
RAO 278 278 0
RPO 250 250 0
RPO 223 223 0
RPO 195 195 0
LPO 168 168 0
LPO 140 140 0
LPO 113 113 0
LAO 85 85 0
LAO 58 58 0
LAO 30 30 0
000
Three Planning Techniques: MP
Field Label Gantry Angle Couch Rotation
RPO 210 0
RT LAT 270 0
RAO 315 0
AIO 340 90
ASO 30 90
LAO 50 0
LSO 90 20
LIO 90 340
LPIO 160 340
PA 180 0
Three Planning Techniques: NCPField Label Gantry Angle Couch
Rotation
LPSO 2 160 50LPSO 1 122 18LAIO 2 101 345LASO 1 79 15LAIO 1 58 342LASO 1 37 16LAIO 1 19 306RASO 2 350 306RAIO 2 323 26RASO 1 302 342RAIO 1 281 10RPSO 2 259 345RPIO 1 238 15RPSO 1 217 345
Plan Evaluations
4 fractions of 12 Gy for total of 48 Gy95 % coverage of PTVRTOG 0915 for OAR verificationChest wall/rib volume at 2cm contourDVH at V10 Gy, V30 Gy, V45 Gy, and V50 GyConformality Index
ResultsConformality Index (CI)RTOG 0813 and 0915Optimum CI less than 1.2Minor Deviations between 1.2 and less than
1.5All three techniques
Optimal or minor deviations40% or 6 out of 15 optimalMP: met 1.2 for all but one patientCOP and NCP: met 1.2 one patient each
Results
1 2 3 4 51
1.1
1.2
1.3
1.4
1.5
Conformality Index
Mixed
COP
NCP
Patient #
Con
form
ali
ty I
ndex
P1 P2 P3 P4 P50
5
10
15
20
25
30
Chestwall Volume 30 Gy
MixedCOPNCP
Patient#
Volu
me
(cc)
P1 P2 P3 P4 P50
1
2
3
4
5
6
7
8
Chestwall Volume 45 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
P1 P2 P3 P4 P50
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Chestwall Volume 50 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
P1 P2 P3 P4 P50
1
2
3
4
5
6
7
Rib Volume 30 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
P1 P2 P3 P4 P50
0.5
1
1.5
2
2.5
3
3.5
4
Rib Volume 45 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
P1 P2 P3 P4 P50
0.5
1
1.5
2
2.5
3
3.5
Rib Volume 50 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
SynopsisDose/Volume relationship
Analysis of three different planning techniques for dose conformality
V30 Gy, V45 Gy, and V50 Gy similar for NCP and MP
CI was met more often for MP than NCP
P1 P2 P3 P4 P50
20
40
60
80
100
120
140
160
180
200
Chestwall Volume 10 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
P1 P2 P3 P4 P50
5
10
15
20
25
30
35
Rib Volume 10 Gy
MixedCOPNCP
Patient #
Volu
me
(cc)
ConclusionCure for early stage NSCLC is surgicalAging population has comorbiditiesMedically inoperable offered SBRTSBRT has late toxicitiesImproved survival decrease toxicitiesAnalyzed 3 planning techniques for volumes
and conformalityNCP offers no dosimetric advantage
increases treatment timeMP is best option