image guided radiation therapy – edward...
TRANSCRIPT
![Page 1: Image Guided Radiation Therapy – Edward Experiencechapter.aapm.org/midwest/SPRINGMTG07/Fan.pdfImage Guided Radiation Therapy – Edward Experience. Outline PET/CT Simulation Manage](https://reader031.vdocument.in/reader031/viewer/2022013022/5f383669d43fb0746a23b3fa/html5/thumbnails/1.jpg)
John Fan, PhDEdward Hospital
Naperville, Illinois
Image Guided Radiation Therapy– Edward Experience
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Outline
PET/CT SimulationManage Respiratory Motion – 4DCT SimulationOn Board Imaging
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Challenges in Radiation Therapy
Identifying the tumorDefining the tumor and targetHitting the targetKnowing the tumor response to radiation
Imaging and image registration is the key for addressing these challenges
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Imaging Techniques are Rarely Used “Solo”
CTMRPETUltrasoundPET/CT Simulation4DCT SimulationOn Board Imaging
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PET for Radiation Therapy Planning
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Why PET/CT Simulation?
Distribution of activity is imagedPhysiology, function, biology
Complementary to (~ anatomic) CT and MRIncreased sensitivity compared to CT alonePET and CT in the same treatment positionAccurate PET/CT fusion
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PET/CT Simulation
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PET can Decrease Target Volume
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PET can Decrease Target Volume
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PET can Increase Target Volume
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PET can Increase Target Volume
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PET can Increase Target Volume
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Are they Moving?
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More Challenges in Radiation Therapy
Identifying the tumorDefining the moving tumor and targetHitting the moving targetKnowing the tumor response to radiation
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Types of Motion
Intra-fractionWithin each fraction (example: lung)
Inter-fractionBetween fractions (example: prostate)
Combined with deformationExample: pancreas
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How to Monitor Breathing?
Chest / abdomen heightVarian RPM System
Belt basedAnzi Medical System (pressure based belt)Philips (pneumatic belt)
Metric spirometry
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Varian RPM
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4D CT Imaging
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4DCT Image Sorting
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4DCT Coronal View
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4DCT Sagittal View
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Manage Respiratory Motion
Tumor moves > 7mm?
4D CT
Use helical CT
GatingRegular breathing pattern?
Contour ITVUse Average study set
No
Yes
Yes
No
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ITV Based on 4DCT
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ITV on Ave Study Set for Planning
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ICRU 62 Target Volume Delineation
GTV – Gross Tumor VolumeCTV – Clinical Target VolumePTV – Planning Target Volume
GTV
CTV
PTV
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ICRU 62 Target Volume Delineation
PTV = CTV + IM + SMIM - Internal Margin, due to physiologic variationsSM - Setup Margin, due to technical factors
PTV
CTV
IM
SM
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ICRU 62 Definition
OAR – Organ at RiskPRV – Planning Organ at Risk Volume
Margin added to OARsOAR
PRV
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GTV from Helical CT
Treatment Fieldfrom Helical CT
ITV
Treatment Fieldfrom ITV
ITV Customized Target Volume
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IGRT can Reduce Internal Margin, Setup Margin, and Margin to OAR
GTV
CTV
PTV
GTV
CTV
PTV
IGRT
OAR
PRV
OAR
PRV
IGRT
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Reduce Treatment Margin
Prostate
Rectum
Bladder
Prostate
Rectum
Bladder
Prostate
Rectum
Bladder
3D Conformal IMRT IGRT
Volume Treated
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On Board Imager – Varian Trilogy
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Image Matching
2D-2D matching of OBI images to DRRsAnatomy matchingImplanted fiducials
3D-3D cone beam CT image match to treatment planning CT images
Anatomy matchingStructure set alignment of GTV, CTV, PTV, or contoured structures to acquired image
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2D-2D Image Match
Orthogonal pair of imagesAP and Lateral – Brain, H&NOrthogonal Oblique's - Pelvis
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Brain: 2D-2D Anatomy Match
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Brain: 2D-2D Anatomy Match
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Pelvis: 2D-2D Anatomy Match
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Spine: 2D-2D Anatomy Match
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Prostate with Implanted Markers
CT
MRI
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Prostate Implanted Marker Match
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Prostate Implanted Marker Match
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Lung CBCT – before matching
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Lung CBCT – matched images
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H&N CBCT 3D-3D Match
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CBCT to Evaluate Tumor Response
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CBCT to Evaluate Tumor Response
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0.0
1.0
2.0
3.0
4.0
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1 2 3 4 5 6 7 8 9 10
Patient
VertLngLatVector
Average Shifts for Prostate
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0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0
Vector
Vert
Lng
Lat
mm
Average Shifts for All Prostate Patients
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0.0
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Patient
VertLngLatVector
Average Shifts for GBM
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0.0 1.0 2.0 3.0 4.0 5.0
Vector
Vert
Lng
Lat
mm
Average Shifts for All GBM Patients
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0.0
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Lng
Lat
Vector
Average Shifts for H&N
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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Vector
Vert
Lng
Lat
mm
Average Shifts for All H&N Patients
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13.36.910.58.6Pancreas
11.36.110.15.8Lung
5.43.84.13.0H&N
6.63.74.54.9Brain (GBM)
7.94.66.15.4Prostate Bed
9.55.26.96.9Prostate
VectorLatLngVertSite
Average Shifts + 2 X Standard Deviation
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IGRT Action Levels – Require Physician/Physics Review
10 mmOther (Lung, Pancreas, etc)
4 mmH&N
5 mmGBM
7 mmProstate (Fiducials or Clips)
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Quality Assurance
Daily QACouch shifts with KV images
Monthly QAKV image – isocenter alignment
AnnualCBCT – isocenter alignment
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Daily QA
Couch Shift Accuracy with KV Imaging
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Monthly QA
KV Image -Isocenter Alignment
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KV Image – Isocenter Alignment
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OBI - Some Limitations
CT resolution and quality of DRR’s are limiting factorsFiducial artifacts on CT imagesArtifacts on CBCT due to organ motionTreatment couch can not tilt and spin
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Conclusion
PET/CT and 4DCT Simulations help us toDelineate target volume and critical structure more accurately Customize, often decrease, internal margin
On Board Imaging gives us valuable tool toReduce setup errorTrack inter-fractional target / organ motionReduce internal & setup marginsTrack tumor response – Adaptive Therapy
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Adaptive Radiation Therapy, or a Black Hole?
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Acknowledgement
Betsy Wang (Physicist)Julie Gruben (Dosimetrist)Mike Slechta (Dosimetrist)Robert Foster (Dosimetrist)
Joy Coldebella (Lead Therapist)Diane Jennings (Therapist)