adaptive radiation therapy - avl - home radiotherapy (art).pdf · radiotherapy procedure tattoo,...
TRANSCRIPT
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Adaptive Radiation Therapy
Jan-Jakob Sonke
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AcknowledgementsDi Yan – William Beaumont HospitalRobert Jeraj – University of Wisconsin Michael Sharpe – Princes Margaret HospitalKristy Brock – Princes Margaret HospitalKatja Langen – MD Anderson Cancer CenterRandall ten Haken – University of MichiganSpring Kong – University of MichiganMarcel van Herk – NKI-AvLSimon van Kranen – NKI-AvLJasper Nijkamp – NKI-AvL
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Content
• Principles of radiotherapy• Anatomical changes• Image guided radiotherapy• Image registration• Adaptive radiotherapy
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Image Guided Radiotherapy
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Radiotherapy procedureTattoo, align and scan patient
Draw target and plan treatment on RTP
Align patient on machine on tattoos and treat (many days)
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Patient Position Changes
The patient moves from day to day
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Organs move from day to day
Organ Motion
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How can we solve this problem ?
1. Use large margins, irradiating too much healthy tissues
2. Use small margins, and risk missing the target
3. Or: use image guided radiotherapy
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Image Guided Radiotherapy
• Image the tumor + organs-at-risk or their surrogates just prior or during treatment
• Assess changes in patient position relative to treatment plan
• Adapt treatment plan (couch shift) to account for changes, increasing treatment precision
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Safety Margins
Verellen et al. Nature Reviews Cancer 2007
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The image guided radiotherapy processPre-treatment Imaging Treatment Planning
In Room Imaging Image Registration& Correction
Treatment Delivery
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image guidance: not a new idea !
First isocentric Co-60 machine in Netherlands at NKI (1960)
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Planar Imaging
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Many In-room Imaging Systems
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Conventional CT- ‘Fan’ beam- 1D detector- 1 rotation = 1 slice
Cone-beam CT - ‘Cone’ beam - 2D detector- 1 rotation = volume (many
slices)
CT Acquisition
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Elekta Synergy Research system at NKI
Frame Rate: 2.7 fps; Acquisition Time: 1 - 4 min; 1-2 mAs/Frame
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NKI high speed reconstruction software (20 s)
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Sample Image
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Image Analysis: comparing with reference image
Reference Image(conventional CT)
Verification image(cone beam CT)
Color-fused image(unmatched)
Reference-Verification image
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Matching on region of interest
Required couch shift: (-3.2, -1.5, -0.6) mm
Required couch shift:(+1.5, -3.2, -6.1) mm
Reference image Verification image Reference image Verification Image
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Pre Correction
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Post Correction
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Margin reduction
0 2 4 6 8 10 12 14 16 18 200
5
10
15
20
Tumor Amplitude [mm]
PTV
Mar
gin
[mm
]
mean Tumormean BoneITV TumorITV Bone
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Uterus interfraction motion
Cervix/uterus on CT
Bladder on CT
Delineations on CBCT
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Uterus motion model
Select 6 bladder fillings based on
this model: • -20 %• 0 %• 33 %• 66 %• 100 %• 120 %
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Plan Selection
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Differential Motion and Shape Variabilty
No couch correction can solve this problemPlanning CT
4D-CBCT
CTV
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Adaptive Radiotherapy
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Adaptive Radiotherapy
The adaptive radiotherapy technique aims to
customize each patient’s treatment plan to
patient-specific variation by evaluating and
characterizing the systematic and random
variations through image feedback and including
them in adaptive planning.
Seminars in Radiation Oncology, 2005
Adaptive radiotherapy will become a new treatment standard.
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The Adaptive Replanning ProcessPre-treatment Imaging Treatment Planning
In Room Imaging Image Registration& Correction
Treatment Delivery
Adaptive Replanning Treatment Assessment
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Adaptive Radiotherapy
Initial treatment plan
Scan first N days Weekly Monitor treatment
Adapt treatment plan
Group-specific ART strategy
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Geometric uncertainties
Series of 9 repeat CT scans during a 25 x 2 Gy treatment schedule
Bladder
Rectum
CTV
Setup errors corrected
CTV shape variation
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PTV marginPlanning CTV
Daily CTV’s
AVG treatment CTV
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PTV marginPlanning CTV
AVG treatment CTV
Systematic error (∑)
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PTV margin
Daily CTV’s
AVG treatment CTV
Random error (σ)
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Systematic error
Initial map Adaptive map
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Deformable Registration
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Multimodality Images
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Multiple Images
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Image Registration
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Image Registration
Finding geometrical correspondencesbetween imaging data sets (2D/3D/4D) that differ in time, space, modality and/or subject
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What is an Image
An image is a N-dimensional mathematical function mapping coordinates to intensity values
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Principle of Image Registration
Floating Image
Fixed Image
InterpolatorInterpolator TransformerTransformer
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General Framework for Image Registration
Fixed image
Floating image
Geometric Transformation
Mapped Image
MetricMetric
TransformerTransformerInterpolatorInterpolator
SimilarityOptimizerOptimizer
AdjustedParameters
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Deformable Registration Example
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planning CT daily CBCT scans CT CBCT overlay
Adapting to shape changes
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CBCT-CT DR – visual verification by movie loop
online couch correction vs deformably registered
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Adapting to shape changesplanning CT daily CBCT scans CT CBCT overlay
weekly adaptated CT adapted CT CBCT overlay
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Dose accumulation during treatment
Planned Accumulated AdaptedAccumulated
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Dose accumulation during treatment
Planned Accumulated AdaptedAccumulated
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Dose accumulation during treatment
Planned Accumulated AdaptedAccumulated
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Dose accumulation during treatment
DD
ose
(Gy)
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Dose accumulation during treatment
DD
ose
(Gy)
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Timing of Rescanning
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Relative Volume
-23% @ wk 6
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Biological Imaging
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Aerts et al, “Identification of residual metabolic-active areas within individual NSCLC tumours using a pre-radiotherapy 18Fluorodeoxyglucose-PET-CT scan,” Radiotherapy & Oncology 91(3):386-92.(2009).
Post RT FDG-PET/CT versus survival
hazard ratio = 3.00 (95 % CI: 1.45 to 6.24; p=0.003)
Classified patients with residual disease after radiotherapy show a worse overall survival
3 month post therapy FDG-PET/CT scan
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CT scan
From Imaging to Target Delineations
FDG-PET/CTDelineated volumes
GTVBoost region
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The Adaptive Replanning ProcessPre-treatment Imaging Treatment Planning
In Room Imaging Image Registration& Correction
Treatment Delivery
Adaptive Replanning Treatment Assessment Biological Response Monitoring
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Limitations / Pitfalls• In room image quality / Field of View
• Single repeat CT scan introduces new systematic errors
• Commercially available tools for “sophisticated “ ART are mostly lacking
• Work flow• Work flow• Work flow
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Summary• IGRT and ART increase the precision of
radiotherapy and thus have the potential to increase the therapeutic window
• Both complex geometric errors and treatment response can be mitigated
• Efficient workflows are required to enable frequent adaptive interventions