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© copyright Image Guided Radiation Therapy Dr. Mark Fisher School of Computing Sciences UEA Norwich UK
© copyright Plan Introduction/Motivation Background State of the Art Current Research Conclusions
© copyright Introduction/Motivation
© copyright Introduction Cancer is currently the cause of 12% of all deaths world wide; 10 million new cases diagnosed annually. Within the European union over 1,5 million new cancer cases are diagnosed every year and over people die of cancer. Most scientists are confident that in the long term significant improvement in cancer cure will come from systematic treatments such as immunotherapy and/or gene therapy and drug targeting. For the time being the surgical removal of the tumour tissue followed by radiotherapy remains the main method of treatment. Source: MAESTRO 2004
© copyright New cases and deaths from cancer - US 2004 Source: American Cancer Society, 2005
© copyright Radiation treatment equipment per million population
© copyright Background
© copyright Background Ionising Electromagnetic Radiation interacts with cells destroying their DNA None-malignant cells can repair themselves but high doses of radiation to healthy tissue can induce secondary malignancies. Both malignant and non- malignant tissue is destroyed BUT...
© copyright Aim of Radiotherapy Treatment I To deliver a high dose of Radiation to the tumour while and a low dose to healthy tissue and organs at risk. –Possible through the use of multiple treatment fields (beams).
© copyright Radiation Therapy Treatment Delivery 1895 Wilhelm Conrad Roentgen saw the bones of his own hand when held between cathode tube and fluorescent screen.
© copyright The Coolidge Tube. William Coolidge of GE with his "hot" cathode tube, The Coolidge tubes also made possible the development of orthovoltage kV X-ray therapy Radiation Therapy Treatment Delivery
© copyright 1937 Varian brothers develop first klystron tube, initially used in Radar Radiation Therapy Treatment Delivery
© copyright 1953 Mullard (Philips) 4 MV double gantry linac. First installed at Newcastle Hospital, This unit featured a nearly isocentric mount, a 1 meter traveling wavetube, MV magnetron, and a false floor. Radiation Therapy Treatment Delivery
© copyright Varian Clinac treatment unit, Today's integrated medical linac has been enhanced by computerized controls and easier operation in the quest for optimal treatment in cancer. 1990s Radiation Therapy Treatment Delivery
© copyright Radiation Therapy Treatment Planning In the early days of radiotherapy, the X-ray beams were rectangular or square in shape and were directed at the tumor from two to four different angles. –Since the dosages delivered were uniform in strength there was some damage to healthy tissue. In the 1970’s conformal RT was developed. This approach used lead-alloy blocks to shape the beam. –The dose was ‘conformed’ to the shape of the tumour, healthy tissue is spared.
© copyright ICRU 50/62 ICRU 50 (1993) and ICRU 62 (1999) define relationships and margins between treatment volumes Report of BIR working party (2003), established in 1999 following initial work by Euen Thompson, NNH
© copyright State-of-the-Art
© copyright Intensity Modulated Radiotherapy Treatment (IMRT) Conceptualised in 1980’s Uses Multi-leaf collimator to vary the dose density within the treatment volume. Allows for much higher dose delivery to malignant tissue. Needs higher precision volumetric planning systems Currently the most widely deployed method in clinical use.
© copyright Beam shaping using MLC
© copyright treatment planning software with inverse treatment planning capability Total Cost approx. £3M each system To treat each patient a medical linac with a multi-leaf collimator ($1.6M) simulation devices and software for establishing patient positioning as well as pre-testing and refining treatment plans
© copyright Comparisons between IMRT and 3D-CRT Treatment Costs
© copyright Source: Alison Vinall, HHUH
© copyright Source: NNUH Data Acquisition
© copyright Treatment Planning
© copyright Computer Planning
© copyright Plan Simulation/Verification
© copyright Five field IMRT beam arrangement for treating prostate
© copyright Treatment Delivery Treatment is delivered over fractions Patient makes several visits to hospital over a period of weeks
© copyright Accounting For Organ Movement “Most of the development of IMRT has taken place assuming that the organs don't move from fraction to fraction and are well represented by their positions determined from some pre-planning 3D imaging study, be it x-ray CT, MR or functional imaging. As the ability to conform to the target has now reached near perfection, attention is now turning to not accepting this limitation and attempting to quantitate organ movement and account for it in IMRT planning and delivery”. “IMRT of the moving patient is like completing a jigsaw on a jelly” Prof. Steve Webb, Royal Marsden Hosp.
© copyright Types of Motion Patient set-up errors –Position-related organ motion which can be minimised if the patient's planning scan is performed while the patient is immobilised and in the treatment position. Inter-fraction motion –i.e. motion that occurs when the target volume changes from day to day. This is a problem for organs that are close to or part of the digestive/excretory system. This work is collated under various headings: gynaecological tumours, prostate (the largest group), bladder and rectum. Intra-fraction –generally due to respiratory and cardiac functions which disturb other organs. This work is collated under headings: liver, diaphragm, kidneys, pancreas, lung tumours and prostate.
© copyright Patient Set-up Errors Stereotactic surgery uses mechanical fixations implanted in the skull to ensure alignment. Gold markers may be implanted in soft tissue
© copyright Passive infra-red reflective marker block used to track chest wall motion during data acquisition, simulation, and treatment. Intra-Fraction Motion: Current Approaches
© copyright Varian RPM respiratory gating
© copyright Gated 4D CT
© copyright Beam’s Eye Views of gated and non-gated treatment volumes
© copyright Gated 4-D CT Movie showing Lung Motion
© copyright MotionView™: addresses intra-fraction deformation This offers particular advantages for targeting lung tumors which move and deform during respiration. Flat panel Amorphous Silicon Detector
© copyright Traditionally, imaging technology has been used to produce three-dimensional scans of the patient’s anatomy to identify the exact location of the cancer tumor prior to treatment. However, difficulty arises when trying to administer the radiation, since cancer tumors are constantly moving within the body IGRT combines a new form of scanning technology, which allows planar or X-ray Volume Imaging (XVI), with IMRT. This enables physicians to adjust the radiation beam based on the position of the target tumor and critical organs, while the patient is in the treatment position. Inter-fraction Motion: Current Approaches Image Guided Radiation Therapy (IGRT)
© copyright Elekta Synergy™ Source: Elekta
© copyright Elekta Synergy™ Synergy allows for co- registration of Cone- Beam CT and RTP data in real-time immediately before treatment delivery
© copyright “For the first time the cone beam system lets us see what we want to hit with our treatment by giving us a continuous set of detailed 3-D X-ray images of the patient when the patient is lying down on the treatment couch. This means we can even move towards better cure rates by safely increasing the doses we deliver in radiotherapy.” (Professor Chris Moore, Consultant Physicist, Christie Hospital) Available from August 2004
© copyright Current Research
© copyright “The future is motion” - Varian annual report 2003 Even when patients are placed in precisely the same position for their daily treatments, some tumors can shift by as much as two to three centimeters over six to eight weeks of therapy. In addition, normal physiological processes like breathing cause some organs and tumors to move significantly during a daily treatment session. As we understand more about tumor motion, we have had to realize that we cannot position patients just on the basis of marks or tattoos on their external anatomy. As the treatments have become more conformal, and as we try to confine the high dose area much more strictly just to where the tumor is, we have to be all the more diligent in knowing exactly where the tumor is, every day.
© copyright MAESTRO WP1.3 - Dynamic RT Objective –To compensate for intra-fraction organ motion by dynamically shaping the beam in real-time (UEA + UCLM). Currently researchers are able to track implanted gold markers © Harvard Medical School
© copyright Portal Video: Respiratory Motion WP1.3 Aims to infer motion without using markers
© copyright Ultimately we hope to simulate Dynamic MLC Control
© copyright ASM: Motion Tracking © Yu Su, School of Computing Sciences, UEA
© copyright Building & Fitting ASM Models © Yanong Zhu, School of Computing Sciences, UEA
© copyright Image Registration via Graph Matching © Muhannad Al-Hasan, School of Computing Sciences, UEA
© copyright Conclusions Several Studies have shown IMRT improves quality of RT –IMRT showed a 92 percent three-year survival rate for early stage prostate patients and a better than 80 percent three-year survival rate for those with an initially unfavorable prognosis. Set-up error and organ motion interferes with the accuracy of radiotherapy, –The important goal of shrinking the treatment margin can only be achieved with better patient positioning techniques. Improvements in electronic portal image devices are needed before widespread use of Dynamic Image Guided RT is possible –WP1.3 should demonstrate it is feasible in a limited number of cases e.g Lung
© copyright Acknowledgements Alison Vinall - Head of Radiotherapy Physics, NNUH Dr. Yu Su, Computing Sciences, UEA Yanong Zhu, Computing Sciences UEA Muhannad Al-Hasan, Computing Sciences, UEA MAESTRO
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Treatment Chart Record of patients radiation therapy history. Must contain: History and diagnosis Rationale for treatment Treatment plan Consent Documentation.
Clinic Logo Goes Here 1 The TrueBeam System Clinic Name Presenter’s name Clinic location Date ™
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The days before Treatment - CT/Simulation - Image Contouring - 3D Treatment Planning - Radiation Field Design (MLC, BLOCKS) - Isocenter Check (Verification.
In the past few years the usage of conformal and IMRT treatments has been increasing rapidly. These treatments employ the use of tighter margins around.
Real-time tumor tracking with preprogrammed dynamic MLC motion and adaptive dose-rate regulation B.Y Yi, S. Han-Oh, F. Lerma, B. Berman, C. Yu.
Awareness - Information - Understanding. What is PEARL? Simply – A Virtual Linac on your desk communicate Linac machine size and sounds to patients.
Stereotactic Body Radiation Therapy (SBRT): The optimal indication for operable tumors in inoperable patients D.Katsochi 1, S.Kosmidis 1, A.Fotopoulou.
Medical Accelerator F. Foppiano, M.G. Pia, M. Piergentili M. Piergentili Genoa 8 March 2004.
Radiotherapy Planning for Esophageal Cancers Parag Sanghvi, MD, MSPH 9/12/07 Esophageal Cancer Tumor Board Part 1.
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Using Radiation in Medicine. There are 3 main uses of radiation in medicine: Treatment Diagnosis Sterilization.
Varian TrueBeam Alamance Regional Cancer Center 2012.
How is radiotherapy given Radiotherapy can be given in two ways: from outside or inside the body. External radiotherapy is the most common method of treatment.
Safety Consideration Software limits on robot controller Limit switches on the robot “wrist” to prevent excess rotations Limit switches on the vertical.
PAMELA Contact Author: CONFORM is an RCUK-funded Basic Technology Programme Charged Particle Therapy Treating cancer with protons and light ions Ken Peach,
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D.G.Lewis Department of Medical Physics Velindre Cancer Centre Whitchurch, Cardiff RT-GRID: Grid Computing for Radiotherapy.
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The Health Roundtable 1-1b_HRT1215-Session_HEGI_JOHNSON_WESTMEAD_NSW Volumetric Modulated Arc Therapy for Stereotactic Body Radiotherapy in Early Lung.
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Comparison of cone beam CT imaging protocols in image guided radiotherapy for prostate cancer H Ariyaratne 1,2, H Chesham 2, J Pettingell 2, K Sikora2,
Optimization of Volumetric Modulated Arc Therapy (VMAT) Planning Strategy Using Ring-shaped ROI for Localized Prostate cancer Kentaro Ishii, Masako Hosono,
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1 Radiotherapy, hadrontherapy and treatment planning systems. Faiza Bourhaleb INFN-Torino University Med 1er-Morocco Radiotherapy Optimization techniques.
Surface contour scanning system - Improved accuracy and efficiency -High level of integration -Multiple applications.
بسم الله الرحمن الرحيم و قل رب زدنى علماً ﴿و قل رب زدنى علماً﴾ صدق الله العظيم.
Somvilai Mayurasakorn, MD. Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University Somvilai Mayurasakorn, MD. Division.
© 2013 MITSUBISHI HEAVY INDUSTRIES, LTD. All Rights Reserved. An example of Technical Innovation Cascade Dynamic Tracking Radiation Therapy System US-Japan.
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Radiotherapy in prostate cancer Dr.Mina Tajvidi Radiation oncologist.
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