Dept of Radiation Oncology MGH

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Presentation transcript:

Dept of Radiation Oncology MGH HST.187: Physics of Radiation Oncology #5. Intensity-modulated radiation therapy: IMRT and IMPT Part 2: IMPT Joao Seco, PhD jseco@partners.org Alexei Trofimov, PhD atrofimov@partners.org Dept of Radiation Oncology MGH March 6, 2007

Flexible field definition, sharper dose gradients IMRT is a treatment technique with multiple fields, where each field is designed to deliver a non-uniform dose distribution.The desired (uniform) dose distribution in the target volume is obtained after delivery of all treatment fields. Flexible field definition, sharper dose gradients Higher dose conformity Improved sparing of healthy tissue IMRT Coll. Work Group IJROBP 51:880 (2001)

Protons vs. Photons Ideal

Intensity Modulated Proton Therapy IMPT = IMRT with protons

Intensity Modulated Proton Therapy Planning approaches Delivery options (inc. MGH plan) Overview of IMPT treatments / development Special considerations for IMPT IMPT vs. 3D-conformal proton vs. photon IMRT in the clinic

Proton depth-dose distribution: Bragg peak Depth = additional degree of freedom with protons H.Kooy BPTC

A. Lomax: “Intensity modulation methods for proton RT” Phys. Med. Biol. 44:185-206 (1999) Field incidence Distal Edge Tracking Field incidence 2D modulation Field incidence 2.5 D modulation Field incidence 3D modulation

IMPT – Example 1 (distal edge tracking)

IMPT – Example 2 (3D modulation)

Treatment planning for IMPT: KonRad TPS (DKFZ) - Bragg peaks of pencil beams are distributed throughout the planning volume - Pencil beam weights are optimized for several beam directions simultaneously, using inverse planning techniques - Output of optimization: beam weight maps for diff energies

Intensity Modulated Proton Therapy Planning approaches Delivery options (MGH plan, other sites) Overview of IMPT treatments / development Special considerations for IMPT IMPT vs. 3D-conformal proton vs. photon IMRT in the clinic

IMRT delivery with multi-leaf collimators

Proton IMPT with Scanning Protons have charge  can be focused, deflected (scanned) magnetically! A proton pencil beam E.Pedroni (PSI)

Proton IMPT with Scanning A “layer” is irradiated by scanning a pencil beams across the volume E.Pedroni (PSI)

Proton IMPT with Scanning Several layers are irradiated with beams of different energies E.Pedroni (PSI)

Proton IMPT with Scanning Complete treatment: a homogenous dose conformed distally and proximally E.Pedroni (PSI)

: pencil beam scanning nozzle for MGH Vacuum Chamber Y Intensity Fast Slow Modulated Beam Z Pair of X Beam Quads monitor Scanning Magnets Continuous scanning. Modulation in current and speed. Pencil beam spot width (s) at the isocenter: ~4-10 mm Several identical paintings (frames) of the same target slice (layer) Max patient field (40x30) cm2

Beam delivery: continuous magnetic scanning in 2D Beam fluence variation along the scan path is achieved by simultaneously varying the beam current and scanning speed: Actual scan is ~50 times faster (0.4 sec)

Scan functions: degeneracy of the solution

Intensity Modulated Proton Therapy Planning approaches Delivery options (MGH plan, other sites) Special considerations for IMPT Overview of IMPT treatments / development IMPT vs. 3D-conformal proton vs. photon IMRT in the clinic

plan delivery The effect of delivery uncertainties in IMPT: fluctuations in the beam position during the scan planned dose distr dose difference due to fluct’s

Beam size in IMPT S Safai

Proton dose in the presence of range uncertainty

Proton dose in the presence of range uncertainty (a dense target) Lower protondose

IMPT – DET (Distal Edge Tracking) Tumor T. Bortfeld

Distal Edge Tracking: Problem with range uncertainty Tumor Brainstem T. Bortfeld

In-vivo dosimetry / range verification with PET K. Parodi (MGH) MGH Radiology

IMPT in the presence of range uncertainties: DET vs. 2.5D DET (+1 mm) DET (+3 mm) DET (+5 mm) 2.5D 2.5D (+1 mm) 2.5D (+3 mm) 2.5D (+5 mm)

Robust IMPT optimization J Unkelbach (MGH) “Standard” optimization Phantom test case Robust optimization

Degeneracy of IMRT solution: different modulation patterns may produce clinically “equivalent” dose distributions

Proton Treatment Field Brass Collimator Proton Treatment Field M Bussiere, J Adams

Scanning with a range compensator

Scanning and IMPT Is scanning = intensity-modulation ?

IMPT delivery: Spot scanning at PSI (Switzerland) A Lomax Med Phys (2004)

PSI gantry radmed.web.psi.ch/asm/gantry/intro/n_intro.html Gantry radius 2m Rotation (a): 185 deg “Step-and-shoot” scanning: 200 MeV proton beam is stopped at regular intervals, no irradiation between “beam spots” magnets range shifter beam monitor sweeper quad 200 MeV

PSI ProSCAN

Scanning and IMPT Is scanning = intensity-modulation ? Is beam scanning = IMPT?

Dose conformation with IMPT 1 field 3 fields 3D IMPT 3D-CPT 1 field 3 fields 1 field SFUD – single field uniform dose ?? 2.5-D IMPT ?? A Lomax (PSI)

Scanning and IMPT Is beam scanning = IMPT ? Is scanning = intensity-modulation ? Is intensity-modulation = IMPT ?

Spread-Out Bragg Peak (SOBP) Wheel rotates @ 10 / sec RM

Spread-Out Bragg Peak (SOBP) Wheel rotates @ 10 / sec RM

Spread-Out Bragg Peak (SOBP) Wheel rotates @ 10 / sec RM

Beam-current modulation: flat-top SOBP

Beam-current modulation: sharper fall-off

IMPT fields for a prostate treatment Double scattering “IMPT”

Intensity Modulated Proton Therapy Planning approaches Delivery options (MGH plan, other sites) Special considerations for IMPT Overview of IMPT treatments / development IMPT vs. 3D-conformal proton vs. photon IMRT in the clinic

Delivery of IMPT: Spot scanning at PSI (Switzerland) Since 1996: Combination of magnetic, mechanical scan Energy selection at the synchrotron + range shifter plates A Lomax Med Phys (2003)

GSI Darmstadt: scanned carbon beam © Physics World D Shardt (GSI)

GSI patient case: Head+Neck Carbon Proton (IMPT) Plan: O. Jaeckel (GSI) Plan: A.Trofimov (MGH)

Depth scanning at GSI (270 MeV C-ions) U. Weber et al. Phys. Med. Biol Weaknesses of lateral scanning: complicated scanning pattern need to interrupt the beam Depth scanning: Target volume is divided into cylinders spaced at ~0.7 FWHM (or 4-5 mm) Cylinders are filled with SOBP (or arbitrarily shaped distribution) Synchrotron , 270 MeV C-12

Scanning directions Fast scanning in depth (2 sec/cylinder) Slower lateral scanning (sweeper magnet) Yet slower azimuthal scanning (gantry rotation)

GSI: IMPT with depth scanning Same dose conformity as with lateral scanning A simpler, uninterrupted scanning pattern Treatment time a factor of 4 longer than with 2D raster scanning GSI: IMPT with depth scanning

Proton Therapy Center – MD Anderson CC, Houston PTC-H 3 Rotating Gantries 1 Fixed Port 1 Eye Port 1 Experimental Port Pencil Beam Scanning Port Passive Scattering Ports Experimental Port Accelerator System Hitachi, Ltd. M. Bues (MDACC) Large Field Fixed Eye Port

Basic Design Parameters for PBS at PTC-Houston Step and shoot delivery Minimum range: 4 cm Maximum range: 30 cm Field size: 30 x 30 cm Source-axis-distance: 250 cm Spots size in air, at isocenter: 4.5 mm for range of 30 cm 5 mm R=20 cm 6.5 mm R=10 cm 11 mm R=4 cm Varian Eclipse TPS Beam 3.2m Scanning Magnets Beam Profile Monitor Helium Chamber Position Monitor Dose Monitor 1, 2 Isocenter Hitachi, Ltd. M. Bues (MDACC)

Intensity Modulated Proton Therapy Planning approaches Delivery options (MGH plan, other sites) Overview of IMPT treatments / development Special considerations for IMPT IMPT vs. 3D-conformal proton vs. photon IMRT in the clinic

Clinical relevance of intensity-modulated therapy (protons vs photons) high Complex anatomies/geometries (e.g., head & neck) with multiple critical structures Cases where Tx can be simplified, made faster Cases where integral dose is limiting (e.g., pediatric tumors) Cases where it may be possible to reduce side-effects (improve patient’s quality of life) IMPT Conformality 3D PT IMXT 3D CRT low Integral dose high J Loeffler, T Bortfeld

Comparative treatment planning Purpose: to identify sites, tumor geometries that would benefit the most from a certain treatment modality or technique 3D-CPT IMPT IMXT J Adams A Chan (MGH) Dose [Gy/GyE]

Nasopharyngeal carcinoma Clinical plan: composite proton+X-ray BPTC: 12 proton fields CTV to 59.4 GyE (33 x 1.8 Gy) GTV to 70.2 GyE (+ 6 x 1.8 Gy) MGH Linac: 4 fields (lower neck, nodes) to 60 Gy J Adams A Chan (MGH) G N Case 1

IMXT plan For delivery on linac with 5-mm MLC 6 MV photons 7 coplanar beams Case 2

IMPT plan Bragg peak placement in 3D Proton beam energies: 80-170 MeV 4 coplanar fields Case 3

Dose-volume histograms (DVH)

Nasopharyngeal carcinoma: dose to tumor Case 2 3D-CPT IMPT IMXT Comparable target coverage

(Some) common complications in Head+Neck Tx Compromised vision Optic nerves, chiasm (“tolerance”: 54 Gy), eye lens (<10 Gy) Compromised hearing Cochlea (<60 Gy) Dysphagia / aspiration during swallowing Salivary glands: e.g. parotid (mean <26 Gy) Larynx, constrictors, supraglottic, base of tongue Suprahyoid muscles: genio-, mylohyoid, digastric Xerostomia (dry mouth) Salivary glands Difficulty chewing, trismus Mastication muscles: temporalis, masseters, digastric Compromised speech ability Vocal cords, arytenoids, salivary glands

Dose-response models: e.g. parotid gland Eisbruch et al (IJROBP 1999) Dose-response models: e.g. parotid gland Saarilahti et al (Radiother Onc 2005) Roesink et al (IJROBP 2001)

Complications may arise from irradiation to doses well below the organ “tolerance” Roesink et al. (IJROBP 2001) Chao et al (IJROBP 2001)

Treatment planning for nasopharyngeal carcinoma Critical normal structures (always outlined): brain stem, spinal cord, optic structures, parotid glands, cochlea ‘Extra’ structures were outlined on 3 data sets esophagus, base of tongue, larynx minor salivary, sublingual and submandibular glands mastication and suprahyoid muscles

Nasopharyngeal carcinoma: sparing of normal structures Superior sparing with protons Brainstem Suprahyoid muscles Sublingual, minor salivary glands

Nasopharyngeal carcinoma: sparing of normal structures (2) IMXT/IMPT better than 3D-CPT Salivary glands Supraglottic structures

Nasopharyngeal carcinoma: sparing of normal structures (3) IMPT may further improve sparing Mastication muscles Oral cavity, palate, base of tongue Cochleae Optic structures, temporal lobes

Nasopharyngeal carcinoma: sparing of normal structures (4) IMPT may further improve sparing Mastication muscles Oral cavity, palate, base of tongue Cochleae Optic structures, temporal lobes

Retroperitoneal sarcoma C. Chung, T.Delaney Radiation dose: 50.4 Gy (E) in 1.8 Gy/fx to 100% of CTV and ›95% of PTV Pre-op Boost of 9 Gy (total 59.4 Gy (E)) Post-op Boost of 16.2 Gy (total 66.6 Gy (E)) Organ at Risk (OAR) constraints Liver: 50% < 30 GyE Small Bowel: 90% < 45 GyE Stomach, Colon, Duodenum: max 50 GyE Kidney: 50% < 20 GyE 3D CPT : added 2% to range and 5mm smear compensation. No PTV in plan IMPT: 5 mm margin to CTV IMRT: 5 mm margin to CTV

36 yo M with myxoid liposarcoma:Transverse IMXT (photon IMRT) 3D CPT IMPT

36 yo M with myxoid liposarcoma: Sagittal IMXT 3D CPT IMPT

Boost IMXT IMPT

PTV Conformity Index (CI)= V95% / PTV Range (N=10) Mean IMXT 1.19 – 1.50 1.35 3D CPT 1.37 – 2.34 1.78 (p=0.032) IMPT 1.05 – 1.30 1.15 (p=0.005) Lower is better

Dmean to OAR Dmean to liver (n=8) Preop boost (n=3) IMXT 0.94 – 24.6 Gy, mean 11.8 Gy 12.0 – 24.6 Gy, mean 16.7 Gy 3D CPT 0.01 – 20.9 Gy, mean 6.61 Gy (p=0.01) _____ IMPT 0.99 – 18.6 Gy, mean 5.73 Gy (p=0.03) 2.8 – 18.6 Gy, mean 9.2 Gy

Dmean to OAR (2) Dmean to stomach (n=8) Preop boost (n=3) IMXT 4.03 – 44.2 Gy, mean 15.4 Gy 13.3 – 43.6 Gy, mean 28.4 Gy 3D CPT 0 – 50.0 Gy, mean 11.8 Gy (p=NS) _____ IMPT 0 – 36.5 Gy, mean 7.85 Gy (p=0.02) 3.5 – 35.2 Gy, mean 16.8 Gy

Prostate carcinoma: (GTV + 5mm) to 79.2 Gy (CTV + 5mm) to 50.4 Gy IMRT 3D CPT IMPT

Prostate: IMRT vs 3D-CPT vs IMPT

Burr Proton Therapy Center (2001-) Patient Population Brain 32% Spine 23% Prostate 12% Skull Base 12% Head & Neck 7% Trunk/Extremity Sarcomas 6% Gastrointestinal 6% Lung 1% T. DeLaney, MD

IMPT vs. photon IMRT More tumor-conformal dose: reduction in dose to healthy organs (including skin)  (?) increased tumor control, reduced complications (acute and late). Proton integral dose smaller (factor 1.5-3) Proton dose conformality much better at low and medium doses, but usually equivalent to IMRT in high-dose range Treatment delivered with fewer fields (2-3 vs. 5-7); Patient-specific devices/QA are not strictly required  more treatments at lower cost Precision of delivery can be increased with robust planning methods, in-vivo range/dose verification

Acknowledgements JA Adams M Bussiere S McDonald, MD H Paganetti, PhD K Parodi, PhD S Safai, PhD H Shih, MD J Unkelbach, PhD Ion Beam Applications T Bortfeld, PhD GTY Chen, PhD T DeLaney, MD J Flanz, PhD H Kooy, PhD J Loeffler, MD M Bues, PhD