IMRT: dal presente al futuro L’esperienza italiana

Ordine Mauriziano - IRCC, Torino

IMRT: IMRT: dal presente al futurodal presente al futuroLL’’esperienza italianaesperienza italiana

U.O.A. Fisica SanitariaOrdine Mauriziano

Reggio Emilia, 14-15 Ottobre 2003

GiuseppeGiuseppe ScielzoScielzo


Contents

IMRT in Italy

- AIFM BEV

- AIRO BEV

- OEV


Breaking the ice ...

I’M aRTist in dose painting


AIFMjournal

Bollettino AIFM


Istituzione del gruppo IMRT-AIFM

Incontro istitutivo del gruppo IMRT-AIFM il giorno Venerdì 17 Gennaio 2003

AIFMIMRT group


IMRT AIFM

groupQuality

assurance

Radiobiological modelling and dose-response function

A computational approach on IMRT

Dosimetry

Multimodality Imaging

Bologna, 27th March 2003


UOA Radiobiologia clinica Università di FirenzeCasa di cura S. Chiara - Firenze:

Dynamic μMLC ERGOGAFchromic MD55 and Exradin micro-chamber Clnical experiences on IMAT

IEO - Milano

μMLC BrainLAB and 3D-Line dMLC.60 dynamic arc stereotacties and 70 prostatesProblem in leaves speed with BrainLab

Ospedale S. Anna - Como

TPS Varian-EclipseClinac 6EX Millenium 120MLCsliding windowX-Omat V, EDR2, EPID and diodes linear arrayPMMA and anthropomorphic RW3 phantoms

Bologna, 27

th March 2003


Istituto Regina Elena – Roma

TPS Helios-CadplanVarian Clinac 2100CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with Films (evaluated with Gamma function)

and ionization chamberIMRT executed on H&N and prostateTests on maximum leaf speed vs predicted position

IRCC di Candiolo e Ospedale Umberto I° - Torino

TPS Varian Helios-CadplanVarian Clinac 600CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with films and ionization chamber21 patientsIMRT in complex cases: the aim is dose escalation and OAR sparing

Bologna, 27

th March 2003


Ospedale S.Giovanni Calibita FatebenefratelliIsola Tiberina - Roma

TPS Helios-Cadplan2X 2100CD Varian 80-MLCsliding windowLoSasso protocolpre-treatment QA with Films, MapCheck and ionization chamberFluence verification every 10 sessions

Vicenza

TPS Pinnaclestep & shootpre-treatment QA with Films and Exradin A14SLtests for small fields and small MU (down to 1 MU)Monte Carlo tests

Bologna, 27

th March 2003


Firenze-CareggiTPS RenderPlanElekta with 80-MLCstep&shootpre-treatment QA with films and ionization chamber

(home-made software for evaluation)prostate patients

Reggio EmiliaTPS Helios-CadplanVarian Clinac 600CD 80-MLC and

Clinac 2100CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with films and ionization chamber80 patientsIMRT for high conformation and fractionated treatment SMART

Bologna, 27

th March 2003


ESTRO Meeting 2003Talks and poster @ Geneva

90

116

152

154

238

239

267

292

295

Torino

Vicenza

Milano

Reggio Emilia

DMLC & IMRT verification

Monte Carlo verification...



Ion chamber for IMRT...

Clinical exp of IMRT...

Clinical exp of IMRT...

IMRT implementation...

IMRT implementation...


AIRO IMRT Group

e.g. Quality assurance in IMRT


Gruppo AIRO IMRT⊗ Treated disease

⊗ Immobilization devices

⊗ Imaging

⊗ Treatment planning

⊗ Pre-treatment plan verification

⊗ Treatment verification (and frequency)

⊗ Tolerance limits on positioning

⊗ Documentation on immobilization

⊗ Immobilisation devices storage and conservation

⊗ Quality manual


IMRT in Italy

Will IMRT guide the exploitation of several relevant good things that already exist in

all the radiotherapy chain ?

Insight view in the clinical practice and a glance into the crystal ball

Great opportunity of starting something new together


IMRT present & futurep overall infrastructure PACS+R&V+RIS

p imaging multimodality

p treatment planning & dose calculation

p virtual vs real simulation

p patient positioning and IGRT

p delivery system

p treatment verification

p tumor response and radiobiological model


Overall infrastructureOverall infrastructure

Record and verify + RIS + Radiology PACSRecord and verify + RIS + Radiology PACS

Integration and verification !Integration and verification !Integration and verification !


TreatmentTreatment segmentsegment

CLINAC 2100C/D

Vision server

Radiology and N

uclear Medecine PA

CS

VerificationInterface

Treatment workstation

CLINAC 2300C/DVerificationInterface

Treatment workstation

CLINAC 600C/DVerificationInterface

Treatment workstation CADPLAN

9 Varis workstations

RT Simulator

9 Vision workstations

PLATO

WorkstationWorkstation segmentsegment

PINNACLE

Varis server

HospitalHospital LANLAN

HUB

HUB

FOCUS

Infrastructure for IMRTInfrastructure for IMRT

Hospital RIS


DICOMtypes

DICOMtypes

DICOM standard for imagesDICOM standard for images

RadiotherapyRadiotherapy

Nuclear Nuclear medecinemedecine

Image Image diagnosticdiagnostic

PACS

Medical Medical PhysicsPhysics

TCTC RMRM γ cameraγ camera

TCTC

PETPET

INTEROPERABILITY & CONNECTIVITYINTEROPERABILITY & CONNECTIVITY

- Computed Radiography - Direct Radiograph

- Computed Tomography- Digital Mammography

- Magnetic Resonance- Ultrasound- Secondary Capture- Nuclear Medicine

DRDR

SimulatorSimulator


Soma-VisionSoma-Vision

Cadplan Umberto ICadplan Umberto I PinnaclePinnacle PlatoPlato

XIO-FocusXIO-Focus

DICOM-RT stuctureDICOM-RT stucture DICOM-RT planDICOM-RT plan

Focal IRCCFocal IRCC2 Cadplans IRCC2 Cadplans IRCC

Focal Umberto IFocal Umberto I

ExomioExomioDICOMRT standard for radiotherapyDICOMRT standard for radiotherapy

RTPXRTPXUmberto I e IRCCUmberto I e IRCC

RT DoseRT Beams Treatment Record, Brachy Treatment Record, Treatment summary record

RT Structure setRT Plan

RT Image

DICOM RT

DICOM RT


Imaging multimodalityImaging multimodality

• CT electron density

• MRI proton density

fMRI morpho-functional

MRSI metabolism

• PET morpho-functional

CT-PET morpho-functional + anatomical

• Molecular Imaging

• CT electron density

• MRI proton density

fMRI morpho-functional

MRSI metabolism

• PET morpho-functional

CT-PET morpho-functional + anatomical

• Molecular Imaging


CT- MRICT- MRI

CT- PETCT- PET

Image registration and fusionImage registration and fusion

The future: Autocontouring?

The future: Autocontouring?

Merging of anatomical-morphological information

Courtesy of Kessler


- Standard MRI imaging

- Spectroscopy on VOI

- Standard MRI imaging

- Spectroscopy on VOI

Morphofunctional imaging: MRSIMorphofunctional imaging: MRSI

Brain Prostate

- Search of metaboilte peaks:

MyoinositolCholine

CreatineN-acetilaspartate

LipidsLactateCitrate

- 3D Maps of metabolites

concentration - Quantitation


Morphofunctional imaging: PETMorphofunctional imaging: PET

Tumor staging

GTV, PTV delineation

Tumor response


Biological targetBiological target


Treatment planning & dose calculationTreatment planning & dose calculation

Inverse planning techniqueDose calculation algorithmsInverse planning techniqueInverse planning techniqueDose calculation algorithmsDose calculation algorithms


Inverse PlanningInverse Planning• Cost function

• Search technique

• Dose calculation

Optimisation with:

• geometrical uncertainties

• beam angle

• EUD

• TCP/NTCP


Geant4 Parallelised Monte Carlo Simulation on Beowulf Cluster of IMRT treatmnent

Grant AIRC2001-02

Geant4 Parallelised Monte Carlo Simulation on Beowulf Cluster of IMRT treatmnent

Grant AIRC2001-02

Dose calculation for IMRT

Dose calculation for IMRT

Pencil beam Pencil beam Superposition/convolutionSuperposition/convolutionMonte CarloMonte Carlo

High dose and density gradient


SimulationSimulation

Simulation: real vs virtual Simulation: real vs virtual Simulation: real vs virtual


Target and OAR are not clearly seen on projection

Target and OAR are not clearly seen on projection

3D visualisation and rendering of target and OAR

3D visualisation and rendering of target and OAR

Low cost (no simulator needed)Low cost (no simulator needed)Correct set-up between CT and

treatment Correct set-up between CT and

treatment

Virtual vs real Virtual vs real

Fast acquisitionFast acquisition

Integration with imaging, TPS and machine

Integration with imaging, TPS and machine

Automatic isocentre positioning with mobile laser

Automatic isocentre positioning with mobile laser

2D visualization2D visualization


Patient positioningPatient positioning

Immobilization system Verification Immobilization system Immobilization system Verification Verification


Termoplastic mask

⇒

Stereotactic system

Immobilization systemImmobilization system

Van Herk,,1998

Courtesy of Agosti


Courtesy of Yan

Image Guided RadiotherapyImage Guided Radiotherapy

4D treatment planning


Real time verification of- Isocenter- Dose distribution

Real time verification of- Isocenter- Dose distribution

Treatment verificationTreatment verification

Dosimetry

- matrix of ion chamber

- amorphous Silicon


New delivery systemNew delivery system

On line organ motion monitoring with infra-red tracking system and X-ray stereo-imagingOn line organ motion monitoring with infra-red tracking system and X-ray stereo-imaging

CyberknifeCyberknifeCyberknife

Ordine Mauriziano - IRCC, Torino Courtesy of Francescon



On line simulation contouring and treatment with CT like MV source On line simulation contouring and treatment with CT like MV source

TomotherapyTomotherapyTomotherapy


Tomotherapy unitTomotherapy unit

Courtesy of Tomotherapy IncCourtesy of Webb



Protontherapy and hadrontherapy in Italy???? Protontherapy and hadrontherapy in Italy????

IMPTIMPTIMPT

Courtesy of Lomax


DVH and dose distributionDVH and dose distributionThanks to C

ozzi Fogliata

IMRT protons3D-CRT

0%

20%

40%

60%

80%

100%

120%

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Midollo

Parotide sinParotide des

PTVIPTVIII

0

20

40

60

80

100

120

PTVIII

PTVI

midollo


Tumor response and radiobiological model

Tumor response and radiobiological model

Immobilization system Verification Immobilization system Immobilization system Verification Verification


Tumor response and radiobiological modelTumor response and radiobiological model

Dose distribution in the target less

homogeneous than in 3DCRT

• greater number of MU: greater leakage

• dose paint: hypoxic regions?

• α/β ratio: prostate case…

• integral dose unchanged

Some radiobiological issue in IMRT

polmones=0.0061

vescicas=1.3

esofagos=3.4

KAB ---- LBK

polmone

esofago

vescica

Courtesy of IFO-Roma


Thanks Thanks Thanks

And the future?

All is possible: just do it.

IMRT: dal presente al futuro L’esperienza italiana

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