Indicazioni cliniche a IGRT-VMAT

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1 Indicazioni cliniche a IGRT-VMAT Andrea R. Filippi Dipartimento di Oncologia Università di Torino RT as a Targeted Therapy Technological advances in treatment planning and delivery provide unique opportunities for improving the precision and, potentially, also the loco-regional effectiveness of RT 1

2 We can kill what we can see, it is often what we cannot see that kills the patient Role of imaging in radiotherapy 2

3 From Image-based RT to Image-Guided Radiation Therapy IGRT aims at decreasing CTV-to-PTV margins from centimeters to millimeters (to an optimum level) Synergy between highly conformal radiotherapy (IMRT) and IGRT 3

4 adaptive means: adaptive dose painting prescription of a non-uniform radiation dose distribution to the target based on functional or molecular images shown to be indicative of the local risk of relapse sub-volume boosting = target within the target painting by numbers = voxel level prescription adaptive means: adaptive dose painting repeat imaging during RT use imaging as a biomarker of response use response map as input map adapt dose distribution: more dose in regions with poor response 4

5 Radiation Oncology Department University of Turin MOSAIQ MONACO ERGO++ VMAT from a clinicians point of view Rapid alternative for conventional IMRT High-conformity planning & delivery for other indications Alternative for stereotactic treatment 3DCRT VMAT IMRT 5

6 Monaco planning software- version 3.0 Patient-setup using cone beam CT 6

7 Clinical activity with VMAT VMAT for brain metastases Conformity: VMAT= Radiosurgery Dose gradients more shallow Multiple arcs needed to deliver the radiosurgery dose Beam on time approximately 5-8 minutes Planning might improve with high definition MLC 7

8 Selected Brain Metastases WBRT (37.5 Gy /15 fractions + concomitant boost 60 Gy/ 15 fractions) Vestibular Schwannomas and Meningiomas Advantages VMAT for VS: 1) High conformity (better than current standard) 2) Decrease in low dose irradiation to normal brain 3) Faster delivery 8

9 Vestibular Schwannomas and Meningiomas Imaging Imobilization Control of respiratory-induced tumor motion Image-guidance Better imaging/better planning/better delivery Transl Lung Canc Res 2012

10 PET-guided nodal contouring definitely supports the use of Involved Fields RT 60 patients included 3% of isolated nodal relapse Van Loon, De Ruysscher IJROBP 2010 Changes in radiotherapy fields Elective nodal RT Involved-field RT 10

11 Analysis of Dosimetric Parameters for lung toxicity in IMRT in 33 patients Variable Average G0-1-2 Average G3-4 Cases p PTV BED MLD Bilateral MLD Omolateral NTCP EUD Bilateral EUD Omolateral Analysis of Dosimetric Parameters for lung toxicity in IMRT in 33 patients Variable Average G0-1-2 Average G3-4 V V V V V V D Cases p

12 G. T., 73 years old, NSCLC II; RT (66 Gy/ fx) Interactive adaptation of the treatment on the basis of daily assessment of changes in tumour volume and response to therapy 12

13 Clinical results obtained so far (2013) Reduced dose to normal structure Reduced acute toxicity Higher percentage of completed treatments Larger volumes treated Improved pathologic response-downstaging in the neoadjuvant setting Salama and Vokes, JCO 2013 IMRT in NSCLC at MD Anderson Jiang et al, Int J Radiation Oncol Biol Phys,

14 Lung Cancer Management, 2012 The INDAR concept: INDividualized Isotoxic Accelerated Radiotherapy De Ruysscher et al, Radiotherapy & Oncology, 2012 Focus on disease sites: Lymphomas 14

15 C. R., 23 years old, HL IIA favorable; 3 ABVD + RT (30 Gy/15 fx) 3DCRT simrt VMAT HT 15

16 3DCRT simrt VMAT HT Fiandra et al, DCRT simrt VMAT HT Fiandra et al,

17 3DCRT simrt VMAT HT 3DCRT simrt VMAT HT 17

18 VMAT/HT vs. 3D-CRT in HL Filippi et al, 2013 S. D. M., 28 years old, PMDLBCL IIB; 5 R-CHOP + ASCT + RT SIB (40 Gy/20 fx; 36 Gy/20 fx) 18

19 M. L., 43 years old, follicular NHL IA; excisional biopsy + RT (30 Gy/15 fx) A. R., 40 years old, Maxillary DLBCL; 6 R-CHOP + 4 LP + RT (30 Gy Gy/15 fx) 1

20 R. P., 48 years old, gastric DLBCL HP+; 3 R-CHOP + RT (30Gy/20 fx) Focus on disease sites: stage I NSCLC 20

21 Comparison between historical RT series and SBRT Senthi et al, Lancet Oncol 2012 UNIVERSITA DEGLI STUDI DI TORINO UNIVERSITA DEGLI STUDI DI TORINO 21

22 Patient Fixation Imaging Treatment Planning Treatment Delivery 4 Patient fixation non-invasive, dual vacuum activated immobilization and fixation system stable immobilization and repeatable positioning by minimizing both voluntary and involuntary patient movement patient comfort range of clinical indications: chest, hip or whole body Radiation Oncology Universityof Torino 22

23 IGRT-VMAT in SBRT Speed of treatment Intrafractional shifts Uncertainty IMRT-mobility No table rotation Better critical organ sparing Dose gradient Inverse Planning Monitor Units DFT 54 Gy/ 18 fx (80% isodose) VMAT 23

24 N. G., 52 y.o., lung adenocarcinoma DFT 60 Gy/ 8 fx (80% isodose) VMAT D. F., 64 y.o., recurrent NSCLC DFT 30 Gy/ 6 fx (80% isodose) VMAT

25 SABR: treatable metastatic sites Lung Liver Adrenal gland Spinal metastases Bone Lymphnodes Radiation Oncology Universityof Torino Mean DFS Tree et al, Lancet Oncology 2013 Radiation Oncology Universityof Torino 25

26 Ricardi et al, Lung Cancer 2012 Radiation Oncology Universityof Torino Single Fraction SABR 26 Gy IGRT-VMAT Filippi et al, Tech Canc Res Treat 2013 Radiation Oncology Universityof Torino 26

27 Radiation Oncology Universityof Torino M. Q., 52 y.o., liver metastases, primary: breast cancer Dose (Gy) DFT 60 Gy/ 3 fx (80% isodose) VMAT 27

28 3 metastases DFT 48 Gy/ 3 fx (80% isodose) IMRT - DMLC A. G., 76 y.o., vertebral metastases (L1, primary: lung cancer) DFT 16 Gy/ 1 fx (80% isodose) VMAT 28

29 VMAT: physics/biology/clinics points Lower doses to a greater volume of surrounding normal tissues This phenomenon is often inappropriately labeled dose dumping, disregarding the fact that, given the same integral dose to the normal tissues, delivering a lower dose to a larger volume is better than delivering a larger dose to a smaller volume for most disease sites Volume considerations must be carefully given for parallel organs, such as the lung, and for young adults/pediatric applications. Yu C & Tang G, Phys Med Biol