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6 th CCO May 2010 Radiation dose painting in Head and Neck treatment: how far are we ? Vincent GREGOIRE, MD, PhD, Hon. FRCR Radiation Oncology Dept., Head.

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Presentation on theme: "6 th CCO May 2010 Radiation dose painting in Head and Neck treatment: how far are we ? Vincent GREGOIRE, MD, PhD, Hon. FRCR Radiation Oncology Dept., Head."— Presentation transcript:

1 6 th CCO May 2010 Radiation dose painting in Head and Neck treatment: how far are we ? Vincent GREGOIRE, MD, PhD, Hon. FRCR Radiation Oncology Dept., Head and Neck Oncology Program & Center for Molecular Imaging and Experimental Radiotherapy, Université Catholique de Louvain, St-Luc University Hospital, Brussels, Belgium

2 6 th CCO May 2010 This house believes that … RO will be (even more) multidisciplinary… RO will be conformal (e.g. IMRT, proton, hadrons)… RO will be tailored (based on imaging and molecular profiling) and adaptive … RO will be associated with targeted agents …

3 6 th CCO May 2010 The current practice: Conformality…?

4 6 th CCO May 2010 2000 Intensity Modulated Radiation Therapy (IMRT) Radiotherapy in HNSCC Adaptive IMRT

5 6 th CCO May 2010 DAHANCA: http://www.dshho.suite.dk/dahanca/guidelines.html EORTC: http://www.eortc.be/home/ Radio/EDUCATION.htm RTOG: http://www.rtog.org/hnatlas/main.htm Conformal radiotherapy and IMRT in Head and Neck Tumors

6 6 th CCO May 2010 Oropharyngeal Carcinoma Which CTV for the neck? Grégoire et al., 2000

7 6 th CCO May 2010 Ant.symphysis menti / platysma Post.hyoid bone / submandibular gland Lat.ant. belly of digastric m. (Ia) mandible / platysma (Ib) Med.ant. belly of digastric m. (Ib) Cra.geniohyoid m./mandible (Ia) mylohyoid m, submandibular gland (Ib) Cau.hyoid bone Level Ia and Ib RP LII LIb LIa CT-based delineation of lymph node levels in the neck: Brussels- Rotterdam consensus guidelines

8 6 th CCO May 2010 H&N IMRT practice heterogeneity among Dutch Radiation Oncologists Rasch et al., 2007

9 6 th CCO May 2010 Oropharyngeal SCC T2-N0-M0 SIB-IMRT: 30x2.3 Gy 30x1.85 Gy PRV Spinal cord Left parotid Right parotid Larynx PTV 55.5 Gy PTV 69 Gy IMRT for Head and Neck Tumors

10 6 th CCO May 2010 ≥ grade 3 mucositis: IMRT vs 3D-CRT Acute toxicity with IMRT Vergeer, 2009

11 6 th CCO May 2010 Parotid gland sparing in IMRT for HNSCC Nutting, 2009

12 6 th CCO May 2010 The current practice: Conformality…? Yes !

13 6 th CCO May 2010 The current practice: Tailoring…?

14 6 th CCO May 2010 The Gross Tumor volume (GTV) Daisne et al., Radiology, 233: 93-100, 2004

15 6 th CCO May 2010 5 cm 18 F-FDG PET CAT Scan Macroscopy Daisne et al, 2004

16 6 th CCO May 2010 Impact of imaging modality on dose distribution Image-Guided Radiation Therapy in HNSCC CT-based target volumeFDG PET-based target volume

17 6 th CCO May 2010 Validation protocol in locally advanced HNSCC Apport de l'imagerie fonctionnelle par Tomographie par Emission de Positrons (TEP) dans le ciblage biologique par radiothérapie de conformation (3D-CRT) et par modulation d'intensité (IMRT) de tumeurs ORL Use of functional imaging with PET for target volume delineation in 3D-CRT/IMRT for head and neck tumors Prof. V. Grégoire, UCL St-Luc, Brussels, Belgium Prof. E. Lartigau, COL, Lille, France Dr. JF Daisnes, Cliniques St-Elisabeth, Namur, Belgium

18 6 th CCO May 2010 Survival is non-flat (higher in resistant areas) Non-flat doseFlat dose More similar survival across entire tumor Far more efficient use of dose Mean Tumor Dose = 2 Gy Courtesy of D. De Ruysscher “Dose painting” by number…

19 6 th CCO May 2010 “Dose painting” : the physics issue

20 6 th CCO May 2010 [ 18 F]-FDG TEPRegistered autoradiography Résolution 2.3 mmRésolution 0.1 mm N. Christian, 2010 Biological heterogeneity

21 6 th CCO May 2010 Metabolism: 18 F-FDG 11 C-Met Proliferation: 76 Br-BFU Hypoxia: 18 F-EF3 Which biological pathways? …

22 6 th CCO May 2010 FDGFLTCuATSM Spatially “complex” target Jeraj et al, 2010

23 6 th CCO May 2010 The current practice: Tailoring…? Great hope but still in the research arena!

24 6 th CCO May 2010 The current practice: Adaptation…?

25 6 th CCO May 2010 C. Monet, 1894 The Cathedral of Rouen 4D-IMRT

26 6 th CCO May 2010 CTMRI (T2)FDG-PET PRE-R/ WEEK 3 WEEK 5 (Week 2) (Week 4)

27 6 th CCO May 2010 Mean slope: -0.93% / treat day (p<0.05) Medial shift: 3.21mm after 25# (p<0.05) Mean slope: -1.03% / treat day (p<0.05) No shift Variation in parotid volumes during RT-CH… (70 Gy – 3 courses on w1, w4, w7) Homolateral parotid Heterolateral parotid Castadot & Lee, 2010

28 6 th CCO May 2010 Variation in CT Target volumes during RT-CH (70 Gy – 3 courses on w1, w4, w7) Castadot & Lee, 2010 Mean slope: -3.18% / treat day (p<0.05) Lateral shift: 1.26mm after 25# (p<0.05) GTV T, CT Mean slope: -2.55% / treat day (p<0.05) Lateral shift: 1.52mm after 25# (p<0.05) CTV T 70 Gy, CT

29 6 th CCO May 2010 Mean slope: -0.47% / treat day (p<0.05) No shift Mean slope: -0.41% / treat day (p<0.05) Medial shift: 1.76mm after 25# (p<0.05) Variation in prophylactic CTVs during RT-CH… (70 Gy – 3 courses on w1, w4, w7) Homolateral CTV N 50 Gy, CT Heterolateral CTV N 50 Gy, CT Castadot & Lee, 2010

30 6 th CCO May 2010 0 → 14Gy 14 → 25Gy25 → 35Gy35 → 45Gy45 → 69Gy Total Dose really received by each volume element of the patient + w2→w0 + w3→w0 + w4→w0 + w5→w0 Castadot & Lee, 2008

31 6 th CCO May 2010 Classic CT-based planningAdaptive PET-based planning 58%67%73%98%100%99%Adaptive PET-based 81%82%83%98%99% Classic PET-based 66%80%85%100% 99%Adaptive CT-based 100% Classic CT-based V 100 V 95 V 90 V 80 V 50 V 10 Planning P<0.001 Geets, 2007 Impact on dose distribution SIB-IMRT 30x2.3 Gy 30x1.85 Gy

32 6 th CCO May 2010 « Classical » CT-based « Classical » PET-based « Real » CT-based « Real » PET-based Adaptive CT-based Adaptive PET-based Homolat Parotid D mean (Gy) 22.0521.6323.8023.2722.9122.09 Heterolat Parotid D mean (Gy) 18.1520.0018.5219.3418.5718.40 SC D 2 (Gy) 39.4939.764142.0437.9038.26 Larynx D 5 (Gy) 65.6366.3365.3766.3565.5765.37 Oral cavity D mean (Gy) 37.8035.1838.7936.1636.0133.35 Mandible D 2 (Gy) 60.5957.5159.5256.7758.3057.27 Homolat Submax gl D mean (Gy) 65.0462.9665.5263.5964.5763.09 Heterolat Submax gl D mean (Gy) 54.9253.7754.9753.6355.1154.58 Skin V 65Gy (cc) 11.668.7812.089.2510.257.24 V 95% (cc) 308.89297.00400.11327.56311.39254.40 Dose distribution after biological adaptive IMRT Castadot & Lee, 2010

33 6 th CCO May 2010 The current practice: Adaptation…? Geometric adaptation, yes! Biologic & dosimetric adaptation, under validation!

34 6 th CCO May 2010

35 6 th CCO May 2010 This house believes that … … conformal …, tailored …, and adaptive … How far are we? Probably not too far … But don’t jump to quickly into routine practice… Wait for validation!

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