online-adaptive robotic radiotherapy - accuray exchange · 2020-02-08 · online-adaptive robotic...
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Online-Adaptive Robotic Radiotherapy
Mischa Hoogeman
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Disclosures and Disclaimer
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
Research agreement with Accuray Incorporated
An honorarium is provided by Accuray for this presentation
Research agreement with Elekta and Varian
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High-Precision and Adaptive Radiotherapy
Conventional
Imaging
Target definition
Treatment planning
Treatment delivery1. Fraction
2. Fraction
3. Fraction
4. Fraction
5. Fraction
6. …
New
Imaging optimized for target definition
High-precision target definition
imaging
1. Treatment planning
delivery
imaging
2. Treatment planning
delivery
MRI, PET-CT, CT …
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Image-Guided Radiation Therapy
Challenges IGRT Offline Adaptive RT Online Adaptive RT
Daily target position Yes
Systematic target shape No Yes
Systematic OAR shape No Yes
Daily target shape No No Yes
Daily OAR shape No No Yes
Lei Dong
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Rationale of Online Adaptive RT
Tumor perspective: Large inter-fraction variability in target position and shape that cannot be corrected by a couch shift or rotation
OARs perspective: Due to position and shape variations of the organs at risk the treatment plan may be far from optimal for the patient’s anatomy during dose delivery
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CyberKnife’s Stereo View
Yes, I can see the
implanted
markers
Can you see
the tumor?
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In-Room Volumetric Imaging: Requirements
Diagnostic CT image quality
▪ Better than current CBCT solutions
▪ Competition with MRLINAC
Keep benefits of CyberKnife system
▪ Non-coplanar beam directions
▪ Tracking
Easy integration, using as much as possible using existing technology
Fast and versatile procedure
▪ ~30 seconds to move the patient from imaging to treatment location
▪ Imaging with patient in treatment position
Support of 3rd party image processing software (e.g. MIM)
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CT-on-Rails System
Papalazarou C, Klop GJ, Milder MTW, Marijnissen JPA, Gupta V, Heijmen BJM, Nuyttens JJME, Hoogeman MS. CyberKnife with integratedCT-on-rails: System description and first clinical application for pancreas SBRT. Med Phys. 2017 Sep;44(9):4816-4827.
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CT-Offset and Tracking
Papalazarou C, Klop GJ, Milder MTW, Marijnissen JPA, Gupta V, Heijmen BJM, Nuyttens JJME, Hoogeman MS. CyberKnife with integrated CT-on-rails: System description and first clinical application for pancreas SBRT. Med Phys. 2017 Sep;44(9):4816-4827.
Robotic treatment couch has no absolute coordinate system
Match daily CT scan to planning CT scan based on the tracking features
Calculate the relative shift of the target
Shift the dose with respect to the tracking features
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Use of In-Room CT in Erasmus MC
Clinical Studies
▪ Check location surgical clips and fiducials for ABPI
▪ Inter and intra-fraction OAR motion around gall duct
▪ Inter-fraction motion OAR around pancreas
▪ Plan of the day for abdominal lymph nodes
Clinical Routine
▪ Troubleshooting with fiducials• Suspicion of fiducial migration
• Only 1 fiducial present
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Motion in SBRT for Locally Advanced Pancreatic Carcinoma
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15-20%
Resectable
30-40%
Unresectable, no progression
40-50%
Unresectable, metastasis
+
Chemotherapy: 8 cycles Folfirinox
SBRT: 5 x 8 Gyprescribed to 80%
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Daily Dose Variations in Organs at Risk
Loi M, Magallon-Baro A, Suker M, van Eijck C, Sharma A, Hoogeman M, Nuyttens J. Pancreatic cancer treated with SBRT: Effect of anatomical interfraction variations on dose to organs at risk. Radiother Oncol. 2019 May;134:67-73.
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Results
Considerable trade-off target coverage/OAR sparing in SBRT for pancreatic cancer
Median increase was statistically significant for V35Gy in all critical structures
Loi M, Magallon-Baro A, Suker M, van Eijck C, Sharma A, Hoogeman M, Nuyttens J. Pancreatic cancer treated with SBRT: Effect of anatomical interfraction variations on dose to organs at risk. Radiother Oncol. 2019 May;134:67-73.
Duodenum Stomach
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Principal Component Analysis (PCA)
P1
P2
PN
Reference organs
Population-based motion model of the OAR
35 LAPC1 patients133 CT scans
Common patterns of OAR
variations
Magallon-Baro A, Loi M, Milder MTW, Granton PV, Zolnay AG, Nuyttens JJ, Hoogeman MS. Modeling daily changes in organ-at-risk anatomy in a cohort of pancreatic cancer patients. Radiother Oncol. 2019 May;134:127-134.
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Modes of Motion: Bowel, Stomach, Duodenom
Magallon-Baro A, Loi M, Milder MTW, Granton PV, Zolnay AG, Nuyttens JJ, Hoogeman MS. Modeling daily changes in organ-at-risk anatomy in a cohort of pancreatic cancer patients. Radiother Oncol. 2019 May;134:127-134.
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Patient Selection Tool to Identify Who May Be at Risk
Magallon-Baro A et al. A model-based patient selection tool to identify who may be at risk of exceeding dose tolerances during pancreaticSBRT. Radiother Oncol. 2019 Oct 9. pii: S0167-8140(19)33105-6.
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Online-Adaptive SBRT for Lymph Nodes
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Online-Adaptive SBRT of AbdominalLymph Nodes
Treatment of oligometastatic disease
Total dose of 45 Gy in 5 daily
consecutive fractions
Dose prescribed at the 90% isodose line
PTV = GTV plus 3 mm
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Adaptive Lymph nodes
Easy Case: GTV quite clear, bowel contour not perfect
Difficult Case: GTV and bowel difficult to see
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Plan Library for Pelvic Lymph Nodes
A Standard Plan C Hot Plan by prescribing to 80%B Different Anatomy Plan
STEAL study; J Nuyttens et al.
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Online Adaptive Workflow
Preparation1. Acquisition of fraction CT scan and import in
MIM software
2. Fraction CT registered to Planning CT based on spine
3. Rigid propagation of dose distribution and target structures
4. Deformable propagation of OARs
5. Visual inspection of propagated contours by RTTs
Plan Selection1. If all OAR constraints are met then select plan
with the highest PTV dose
2. Otherwise select the plan with the lowest dose to the OARs
3. If it is too difficult to decide then take plan A
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Plan A
Plan B
Plan C
Dose
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Results
Results of the first 12 patients
Primary tumor
▪ 6 Colorectal
▪ 3 Prostate
▪ 3 Other
Localization
▪ 8 Abdomen
▪ 4 Pelvis
Medium minimum distance GTV-Bowel: 8.6 mm
Re-planning was performed for 3 patients:
▪ Due to a constraint violation for both duodenum and stomach
▪ A mismatch with the tumor, found at the moment of the first daily CT scan
10% more dose to the tumor was given in 24% of the fractions, but can go up to 40%
Plan B (different anatomy) was not selected
Nuyttens et al. 2020
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Conclusions
CT scanner was integrated successfully with CyberKnife system
Integration with tracking system has been tested and is now being prepared for clinical use
Library-of-plans based Plan of the Day strategies were introduced using MIM software
Big step to clinically implement adaptive workflow with RTTs in charge. Limitations what RTTs (and physics) are allowed to do.
Need a physician to be present at the treatment?
Automation and quantitative decisions needed for RTTs based on automatically segmented contours
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Acknowledgements
Maaike Milder
Wilhelm den Toom
Joost Nuyttens
Alba Magallon
Patrick Granton
Lauro Moi
The CyberKnife team
and many others …