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Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
This work aims to compare ITVs defined using 4DCBCT data in two treatment planning systems (TPS) and to assess their impact on planned dose
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Background: Lung SABR in NT
Introduction: ITV in lung SABR
Method: ITV definition using 4DCBCT
Validation: Validation of 2 methods
Results: Volume Analysis + Plan Evaluation
Discussion: Uncertainty + Adv./Disadv.
Conclusion: Major findings + implications
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Only RT centre in NT
Low population ◦ 30-40 patients per day
High Indigenous population◦ High incidence lung cancer
◦ Advanced presentations
◦ High COPD
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Alan Walker Cancer Care Centre - AWCCC
CT
•Toshiba Wide Bore
•No 4DCT
TPS•Pinnacle
Linac
• 2 Elekta Synergy
• MLCi2
• 4D CBCT XVI Symmetry
SABR for lung only
First patient treated October 2016
Total 16 patients treated to date
3DCRT + non-coplanar beams
48Gy / 4 Fx
Dose escalation planned for 2018
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
SABR for lung cancer relies on accurate definition of tumour motion using an internal target volume (ITV).
Typically 4DCT is utilised to define the ITV
Two methods of ITV definition using 4-dimensional cone-beam CT (4DCBCT) data are described.
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Manual Method - Pinnacle
MIP Method - Monaco
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
End-to-end testing
Localisation of moving target
Tumour remains within ITV
Moving/static dose
<1% difference
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Patient Ratio
1 0.904
2 0.986
3 0.750
4 0.577
5 0.869
6 0.466
7 0.364
8 0.491
9 0.509
10 0.447
11 0.734
12 0.544
13 0.820
14 0.810
15 0.7840
5
10
15
20
25
30
35
40
45
50
55
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
ITV
Volu
me (cm
3)
Patient
ITV Manual
ITV MIP
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
All ITVs reduced
0
10
20
30
40
50
60
70
80
90
100
110
120
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
PT
V V
olu
me (cm
3)
Patient
PTV Manual
PTV MIP
Patient Ratio
1 1.023
2 1.086
3 0.886
4 0.873
5 0.920
6 0.724
7 0.604
8 0.843
9 0.754
10 0.620
11 0.760
12 0.726
13 0.931
14 0.907
15 0.981
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
9/15 > 10% difference
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Replans in Pinnacle
Isocentre
Beam angles
Target coverage maintained
2 patients excluded - PTV coverage could not be met
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
0
2
4
6
8
10
12
14
16
18
20
1 2 3 4 5 7 8 9 11 12 13 14 15
Num
ber
OA
R C
onstr
ain
ts
Patient
Decreased
Increased
Unchanged
All 13 patients experienced dose reduction for one or more OAR constraints◦ Average 75% OAR doses decreased by replan
6/13 patients had one or more OAR reduced ≥10%
Most clinically insignificant
3 cases reviewed
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
0
2
4
6
8
10
12
14
16
18
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Volu
me (%
)
Patient
Lungs - GTV: V20 <10%
ITV Manual
ITV MIP
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Patient 11 Constraint Planning Aim ITV Manual ITV MIP
CI 100 % ≤1.2 / ≤1.2 1.03 1.08
CI 50 % <3.35 / <3.47 3.27 3.54
LUNGS -GTVV20 <10 10.69 9.72
Mean (Gy) <20 7.0 6.55
SPINAL CANAL
Point max (Gy) <26 6.5 6.45
0.35cc Vol. max (<20.8Gy) 5.4 5.8
1.2cc Vol. max (<13.6Gy) 4.6 4.3
HEARTPoint max (Gy) <34 18.62 17.88
15cc Vol. max (<28Gy) 13.7 13.4
GREAT VESSELSPoint max (Gy) <49 16.76 14.76
10cc Vol. max (<43Gy) 9.1 8.5
OESOPHAGUSPoint max (Gy) <30 9.15 9.04
5cc Vol. max (<18.8Gy) 7.7 7.4
SKINPoint max (Gy) <36 19.17 18.55
10cc Vol. max (<33.2Gy) 13.8 13.5
TRACHEA & LARGE BRONCHUS
Point max (Gy) <34.8 17.15 15.3
4cc Vol. max (<15.6Gy) 0.9 0.8
CHEST WALL/RIBSPoint max (Gy) <40 47.18 45.4
1cc Vol. max (<32Gy) 37.7 37
NORMAL TISSUE %<68.97 / <66.66
66.78 63.96
Patient 11
48Gy/4Fx
PTV Manual97.507cm3
PTV MIP74.115cm3
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Patient 5 Constraint Planning Aim ITV Manual ITV MIP
CI 100 % ≤1.2 / ≤1.2 1.07 1.03
CI 50 % <3.67 / <3.80 4.02 3.88
LUNGS -GTVV20 <10 16.29 14.29
Mean (Gy) <20 10.14 9.19
SPINAL CANAL
Point max (Gy) <26 13.38 17.5
0.25cc Vol. max (<22.5Gy) 11.8 13.4
0.5cc Vol. max (<13.5Gy) 11.6 12.5
HEARTPoint max (Gy) <63 23.86 23.36
15cc Vol. max (<28Gy) 16 15.7
GREAT VESSELSPoint max (Gy) <63 25.34 25.16
10cc Vol. max (<47Gy) 8.7 6.7
OESOPHAGUSPoint max (Gy) <63 18.11 18.75
5cc Vol. max (<27.5Gy) 9.5 7.7
SKINPoint max (Gy) <32 28.57 27.47
10cc Vol. max (<30Gy) 15.9 15.6
TRACHEA & LARGE BRONCHUS
Point max (Gy) <63 32.59 17.53
4cc Vol. max (<18Gy) 1.6 1.15
CHEST WALL/RIBSPoint max (Gy) <40 40 39.82
1cc Vol. max (<32Gy) 32.5 32.35
NORMAL TISSUE %<64.62 / <63.61
70.2 69.84
Patient 5
60Gy/8Fx
PTV Manual63.1022cm3
PTV MIP58.074cm3
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Patient 4 Constraint Planning Aim ITV Manual ITV MIP
CI 100 % ≤1.2 / ≤1.2 1.03 1.05
CI 50 % <4.97 / <5.05 5.86 5.96
LUNGS -GTVV20 <10 1.03 0.92
Mean (Gy) <20 1.52 1.4
SPINAL CANAL
Point max (Gy) <26 6.85 6.83
0.35cc Vol. max (<20.8Gy) 6.6 6.5
1.2cc Vol. max (<13.6Gy) 6.4 6.3
HEARTPoint max (Gy) <34 1.44 0.63
15cc Vol. max (<28Gy) 0.4 0.3
GREAT VESSELSPoint max (Gy) <49 12.61 11.36
10cc Vol. max (<43Gy) 6.8 4.3
OESOPHAGUSPoint max (Gy) <30 6.29 6.23
5cc Vol. max (<18.8Gy) 0.5 0.4
SKINPoint max (Gy) <36 14.46 14.2
10cc Vol. max (<33.2Gy) 9.6 9.3
TRACHEA & LARGE BRONCHUS
Point max (Gy) <34.8 6.41 6.02
4cc Vol. max (<15.6Gy) 3.9 3.3
CHEST WALL/RIBSPoint max (Gy) <40 59.27 59.33
1cc Vol. max (<32Gy) 41.6 41
NORMAL TISSUE % <50 / <50 54.06 49.45
PTV Manual9.34cm3
PTV MIP8.15cm3
48Gy/4Fx
Patient 4
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Contouring – assessed through team meeting
Motion artefacts in CT and CBCT
Different position/breathing pattern from CT to CBCT
Fusion
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Disadvantages
Poor Image quality
Additional fusion
Additional machine time
Dose calculation on free breathing
Increased QA
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Advantages
No 4DCT required
Tumour motion captured in treatment position
Adequate tumour coverage
Tumour motion verified at treatment
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Manual MIP
Image quality XTarget coverage X
OAR doses XTime X
Accuracy
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
ITV definition using Symmetry validated for Lung SABR ◦ Manual + MIP◦ Pinnacle + Monaco
MIP method produces smaller volumes more indicative of true tumour motion most of the time◦ Exceptions – lateral or inferior located tumours
Manual method more likely to over-contour
MIP ITVs resulting in smaller PTVs reduced OAR dose in all cases although reduced target coverage in some cases
Although majority of OAR doses were subsequently reduced, clinically significant plan changes were rare and therefore overall plan acceptability was comparable
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW
Jeremy Plawecki, Senior RT – planning
Dr. Thanuja Thachil, RO – contouring
Elekta – Monaco education station
Elekta 2017 Australasian User Meeting12th November 2017, Newcastle, NSW