external beam radiation therapy special procedures kent a. gifford, ph.d., acknowledgements to :...
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External Beam Radiation External Beam Radiation Therapy Special Therapy Special
ProceduresProcedures
Kent A. Gifford, Ph.D., Kent A. Gifford, Ph.D., Acknowledgements to : Karl L. Prado, Acknowledgements to : Karl L. Prado,
Ph.D., Charles Bloch, Ph.D., Peter Balter, Ph.D., Charles Bloch, Ph.D., Peter Balter, Ph.D., Gurpreet Arora, B.S.Ph.D., Gurpreet Arora, B.S.
Department of Radiation PhysicsDepartment of Radiation Physics
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Total Body IrradiationTotal Body Irradiation
IndicationsIndications TechniquesTechniques Dosimetry DataDosimetry Data ExamplesExamples
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TBI: Clinical IndicationsTBI: Clinical Indications
Preparation for marrow or stem-cell Preparation for marrow or stem-cell implantationimplantation Suppress immune system to prevent Suppress immune system to prevent
rejectionrejection Rid body of tumor cells not reached by Rid body of tumor cells not reached by
chemotherapeutic agents (e.g. CNS)chemotherapeutic agents (e.g. CNS)
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half body, adjacentdirect fields
TBI TechniquesTBI TechniquesAAPM Report 17, figure 1.AAPM Report 17, figure 1.
single source,long SSD
source moves horizontally
patient moves horizontally
half body, directand oblique fields
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TBI TechniquesTBI TechniquesAAPM Report 17, figure 1.AAPM Report 17, figure 1.
four sources
two horizontal beams
single source, short SSD
two vertical beams
head rotation
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MDACC “Classic” TBIMDACC “Classic” TBI
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MDACC TBI Techniques:MDACC TBI Techniques:Mick-Radio Nuclear StandMick-Radio Nuclear Stand
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Total Skin IrradiationTotal Skin Irradiation
High Dose-Rate Total Skin Electron High Dose-Rate Total Skin Electron (HDTSE-) Treatment: Technique (HDTSE-) Treatment: Technique DescriptionDescription
IndicationsIndications MethodologyMethodology Data / CalculationData / Calculation Dose Verification (TLD)Dose Verification (TLD)
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MDACC TSEI techniqueMDACC TSEI technique(modified Stanford technique)(modified Stanford technique)
2 angled beams (90°±23°) for 2 angled beams (90°±23°) for uniform coverage and reduced uniform coverage and reduced total body dosetotal body dose
patient is 25 cm behind lucite patient is 25 cm behind lucite plateplateimproved dose uniformityimproved dose uniformity(6 fields w/plate 8 fields (6 fields w/plate 8 fields w/o plate, Holt JG, Perry DJ. w/o plate, Holt JG, Perry DJ. Med. Phys.Med. Phys. 99:769-776(1982)):769-776(1982))
increased dose to self increased dose to self shielded areas by diffusionshielded areas by diffusion
6 positions, every 606 positions, every 60°°
2 angled beams (90°±23°) for 2 angled beams (90°±23°) for uniform coverage and reduced uniform coverage and reduced total body dosetotal body dose
patient is 25 cm behind lucite patient is 25 cm behind lucite plateplateimproved dose uniformityimproved dose uniformity(6 fields w/plate 8 fields (6 fields w/plate 8 fields w/o plate, Holt JG, Perry DJ. w/o plate, Holt JG, Perry DJ. Med. Phys.Med. Phys. 99:769-776(1982)):769-776(1982))
increased dose to self increased dose to self shielded areas by diffusionshielded areas by diffusion
6 positions, every 606 positions, every 60°°
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MDACC TSEI techniqueMDACC TSEI technique(modified Stanford technique)(modified Stanford technique)
ANT
LPORPO
1st day of cycle
POST
RAOLAO
2nd day of cycle
laser
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Stanford dual beam techniqueStanford dual beam technique
feet straight ahead or pointed slightly feet straight ahead or pointed slightly outwards for better balanceoutwards for better balance
elbows at or above shoulder levelelbows at or above shoulder level arms parallel to the scatter platearms parallel to the scatter plate
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QA - Patient TLD’sQA - Patient TLD’s
TLD’s are taped to the patient’s skin TLD’s are taped to the patient’s skin and irradiated for one cycle (12 and irradiated for one cycle (12 beams)beams)
reference TLD’s are irradiated using reference TLD’s are irradiated using a 10x10 cma 10x10 cm22 field of 9 MeV electrons field of 9 MeV electrons atat2.0 cm depth (100 cm SSD) in an2.0 cm depth (100 cm SSD) in anacrylic phantomacrylic phantom
TLD’s are taped to the patient’s skin TLD’s are taped to the patient’s skin and irradiated for one cycle (12 and irradiated for one cycle (12 beams)beams)
reference TLD’s are irradiated using reference TLD’s are irradiated using a 10x10 cma 10x10 cm22 field of 9 MeV electrons field of 9 MeV electrons atat2.0 cm depth (100 cm SSD) in an2.0 cm depth (100 cm SSD) in anacrylic phantomacrylic phantom
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SRS: Available Systems-SRS: Available Systems-
Gamma KnifeGamma Knife Radionics Xknife/XplanRadionics Xknife/Xplan BrainlabBrainlab CyberknifeCyberknife Others (many “homemade”)Others (many “homemade”)
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Delivery techniquesDelivery techniques
201 intersecting beams (Gamma 201 intersecting beams (Gamma Knife)Knife) spherical dose distributionsspherical dose distributions
Arcs with circular collimators (1-4 cm)Arcs with circular collimators (1-4 cm) ellipsoid dose distributionsellipsoid dose distributions
Multiple fields, shaped with miniature Multiple fields, shaped with miniature MLCMLC arbitrary dose distributions arbitrary dose distributions IMRTIMRT
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Stereotactic RadiosurgeryStereotactic Radiosurgery
Elimination of Elimination of motion & setup motion & setup errors means errors means smaller field size smaller field size can be usedcan be used
Reduction in field Reduction in field size allows higher size allows higher dose per fraction, dose per fraction, and reduction in and reduction in number of fractions number of fractions (1 to 5)(1 to 5)
Large dose to small Large dose to small lesions with lesions with minimal dose to minimal dose to surrounding tissue.surrounding tissue.
Single fraction Single fraction ““Out-of-town” Out-of-town”
patientspatients Patients in poor Patients in poor
healthhealth Other patients who Other patients who
might be burdened might be burdened by protracted by protracted treatment.treatment.
Bloch, Ph.D.
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SRS QASRS QA
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TreatmentTreatment
Typically 5 arcs, about 60 degree Typically 5 arcs, about 60 degree each.each.
5-10 MU/degree 5-10 MU/degree 300 - 600 MU/arc. 300 - 600 MU/arc. 300 MU/min 300 MU/min 1-2 minutes per arc. 1-2 minutes per arc. Total treatment is 5-10 min of beam Total treatment is 5-10 min of beam
time.time. Room entries between arcs to move Room entries between arcs to move
couch and re-check patient couch and re-check patient alignment.alignment.
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Gating Study-Left BreastGating Study-Left Breast
By Gurpreet Arora, B.S.
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PROBLEM: Thoracic tumors PROBLEM: Thoracic tumors movemove
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Planning on the three CT setsPlanning on the three CT sets
CT at Inspiration CT at Expiration CT during Free Breathing
Combined to form ITVs
By Peter Balter, Ph.D. and Lei Dong, Ph.D.
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The GE system for 4D The GE system for 4D scanningscanning
Uses Varian RPMto monitor respiration
GE PET/CT (can be used on any GE CT scanner)
By Peter Balter, Ph.D.