Radiation Therapy at RCC-NW: New Technology New Treatment New Level of Care Kasey Etreni BSc., MRT(T), RTT, CTIC Melanie Zappitelli BSc., MRT(T), RTT May 4, 2012 We participated on the machine selection committee that chose Elekta’s linear accelerators

Disclosure No potential conflicts of interest have been identified for this presentation.

New Technology: Elekta Infinity Linear Accelerators New technology @ our centre is focused around our 2 new Tx machines. The Infinity is Elekta’s “top of the line” linear accelerator and has the most advanced capabilities available for imaging the Tx delivery today. Our 1st new machine will be installed within the next couple of months and the second will follow next year.

New Technology: Elekta Infinity Linear Accelerators MLCi2 - Digital Multi-Leaf Collimator Hexapod - 6 Degrees of Freedom Treatment Bed XVI - X-Ray Volume Imaging High Dose Rates - > 500 mu/min > 600 mu/min The technology we are going to highlight in this presentation are:

Digital Multi-Leaf Collimator A multileaf collimator of MLC is a device in the head of the machine made up of individual leaves. The leaves moves independently in and out of the path of the beam in order to block the beam (allowing us to conform to tumor) MLCi2 – 80 leaves – 1cm width ability to interdigitate (interlock like clasped hands) Upgrade as soon as Health Canada Approval to Agility with 160 interdigitating leaves with 0.5cm width with speeds of 65mm/s Here are 4 pictures showing leave shape

Hexapod 6 Degrees of Freedom Treatment Bed When setting up a patient for Tx this bed allows for correction of translational coordinates (x,y,z) and rotational coordinates (pith, roll yaw) Allows for more accurate positioning of the patient and therefore more accurate Tx delivery.

3D X-Ray Volume Imaging Low dose 3D imaging Increased treatment accuracy Ability to assess changes in tumor & patient anatomy Simultaneous acquisition and reconstruction XVI – These machines have the ability to acquire 3D cross sectional images of the patient prior to Tx delivery so we can align the patient accurately daily. These images are then overlayed with the CT images used to plan the RT and fine adjustments are made to wnsuer the patient is accurately aligned for treatment. Using RT judgement, we can align soft tissue size, shape, pos’n critical organs, tumor and bony alignment seen in 3D eliminate the need for internal markers (gold seeds) overlay structures and isodoses defined in Tx planning The images also allows us to assess changes in tumor such as shrinkage and pt anatomy changes due to weight loss – allowing us to replan if necessary.

Higher Dose Rates Enables faster treatment delivery times Better for patients – less time on treatment bed 6MV > 500 mu/min 15MV > 600 mu/min High Dose rates – Currently the machine we treat with a dose rate of 300mu/min for low energy Xrays and 500 mu/min fir high energy Xrays. Our new machines will treat at 500 mu/min for low energy and greater than 600 mu/min for high energy Increased rate means less times to deliver RT

New Treatments/Techniques New technology enables: VMAT Volumetric Modulated Arc Therapy SBRT Stereotactic Body Radiation Therapy New technology enables these possibilities:

VMAT Single or multiple beams - uninterrupted arcs High dose conformance Dramatically reduces treatment delivery time The first new technique that these machine have the ability to deliver is - Volumetric Modulated Arc Therapy – which is a form of rotational IMRT. With Elekta VMAT, single or multiple radiation beams sweep in uninterrupted arcs around the patient dramatically speeding up Tx delivery. Conventional Tx takes 12-15 mins to deliver now can be delivered in a little as 2mins. This technique delivers high radiation does to the tumor target while reducing dose to surrounding healthy tissue and organs. Quicker Tx also means less time on the bed for the patient and also decreases the risk of patient movement during Tx delivery.

SBRT Maximum precision and accuracy required Allows for hypo-fractionated treatment regimens Dose delivered in 1-10 treatments More resources & more machine time Sterotactic Body RT – allows us to precisely target tumors with less damage to surrounding tissue. Customizing RT to account for patient breathing and organ motion. Allows us to deliver a high dose in a short fractionation time. Hypofractionation Early 20s and 30s doses were determined 180 cGy -200 cGy /day in 20-30 Txs However slighlty higher today in both dose and number of Txs SBRT – typically 500 – 2000 cGy ;/ day in 1-10 Txs Clinical trials - 2500 – 3400 cGy in a single Tx 6000 – 7000 cGy in 8-10 Txs Better for patients – less visits to cancer centre However, more resources and more machine time needed NOT for every patient – 2X3 times longer – presently used in patients with cancer of the lung, pancreas, prostate, liver

More accurate and faster treatment & delivery techniques New Level of Care New Technology More accurate and faster treatment & delivery techniques Improved Patient Care What does this system do specifically for RT? Complete management system Records and verifies all linear accelerator settings for all Txs Records all Tx delivery data and images and tracks daily set up corrections made based on daily imaging.

New Level of Care Fully integrated Oncology Information System - MOSAIQ Increased safety & efficiency Improved communication Complete patient information system Paperless environment Improved Patient Care

Thank You! Questions?