IGRT 3D/4D

27 Jan 2011

Vera Fernandes
Radiographer Senior II
Vera.Fernandes@rmh.nhs.uk
Royal Marsden NHS Foundation Trust Sutton
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CONTENTS

PROBLEMS WITH MOTION

SOLUTIONS

IGRT & ABC – LUNG

FUTURE
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3D/4D

THREE-DIMENSIONAL FOUR-DIMENSIONAL
(3D) (4D)
CT-based

VOLUME MOTION
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3D RT
Traditionally:

o Treatment volume is defined on static CT image

Does not precisely define tumour in motion due to respiration

o Target may move in and out of treatment field

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3D RT
o CT scan time: gratter compared with the time scale of many organ motions

o Patients move and breath

o Heart beats

o Intestine movements

o Gas

o Variable filling of the rectum and bladder

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PROBLEMS

GEOMETRIC UNCERTAINTIES

o Uncertainties occurring during treatment preparation (Systematic errors)

o Setup error & organ motion on the CT scan

o Delineation errors

o Equipment calibration errors

o Uncertainties occurring during treatment execution (Random variations)

o Interfraction variations
4D
o Intrafraction variations
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PROBLEMS

o Increase PTV to include the target in motion

Expand the PTV to cover the maximum ranges of target motions along all three directions

Treatment planning and dose delivery

Large volume of normal tissue is exposed unnecessarily to high

radiation dose

– Limiting total dose and dose / #

HOW TO MANAGE THE

4th DIMENSION?
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PROBLEMS WITH MOTION

SOLUTIONS

IGRT & ABC – LUNG

FUTURE
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SOLUTIONS

o Breath-hold technique

Radiation is delivered with breath-hold

o Tracking technique

Radiation is delivered by tracking the motion of the target

• Dynamic Tracking

• Real time Tracking

o Gating technique

Gated radiation delivery is based on the selected phase of breathing cycle

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SOLUTIONS

o Breath-hold technique

Radiation is delivered with breath-hold

o Tracking technique

Radiation is delivered by tracking the motion of the target

• Dynamic Tracking

• Real time Tracking

o Gating technique

Gated radiation delivery is based on the selected phase of breathing cycle

 ACTIVE BREATHING
COORDINATOR
(ABC)
Mouthpiece & Balloon
Filter Kit valve
Single Use
only
Transducer turbine Transducer balloon Balloon valve cable
and pick up assembly valve coupler (connects to control module)

Breath hold
volume
(Threshold Vol)

Tidal
volume

Breath
hold time
Trolley
attachment
Courtesy of Helen McNair
 TREATMENT

Balloon valve closes

Switch Linac on
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SOLUTIONS

o Breath-hold technique – our experience

Radiation is delivered with breath-hold

o Tracking technique

Radiation is delivered by tracking the motion of the target

• Dynamic Tracking - e.g. Cyberknife

• Real time Tracking – e.g. Calypso System

o Gating technique

Gated radiation delivery is based on the selected phase of breathing cycle

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SOLUTIONS

o Breath-hold technique – our experience

Radiation is delivered with breath-hold

o Tracking technique

Radiation is delivered by tracking the motion of the target

• Dynamic Tracking - e.g. Cyberknife

• Real time Tracking – e.g. Calypso System

o Gating technique

Gated radiation delivery is based on the selected phase of breathing cycle

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PROBLEMS WITH MOTION

SOLUTIONS

IGRT & ABC – LUNG

FUTURE
 INDICATIONS - ABC

• Lung

• Breast

• Oesophagus

• Liver/Gallbladder

• Pancreas

• ....
 ABC RMH

Developed1997
John Wong 2011

Clinical trials
2002
Commercial product 2004 October 07
Confidence USE OF ABC
Feb 02
CLINICAL PRACTICE
period
Recruitment AND
for 2 Studies CLINICAL TRIALS
• The reduction in PTV size with ABC resulted in an 18–25% relative reduction in
physical lung parameters.

• PTV margin reduction has the potential to spare normal lung and allow dose-
escalation if coupled with image-guided RT.

• Patient immobilisation is as important as attempts to control tumour motion.

•ABC device can be used throughout radical RT for NSCLC with reproducible intrafraction
tumour position

•Tumour position shift over time (interfraction variation), and patient setup errors, a
reduction in the size of the PTV margin is nevertheless not possible without
IMAGE GUIDANCE OR IMPROVED SETUP
 HOW TO MANAGE THE

4th DIMENSION?

CONTROL THE TARGET

“ELIMINATE” INTRAFRACTION MOTION

 TRAINING
Prior CT scan

CT SCAN
EXPORT IMAGES TPS PLANNING
WITH ABC

REGISTRATION AND
EXPORT IMAGES TO XVI DEFINITION OF PATIENT SETUP
CLIPBOX

CONE BEAM
MATCHING CORRECTION
TREATMENT
AQCUISITION DELIVERY
WHAT’S THE ADVANTAGE
OF
USING ABC & CBCT?

IGRT TO REDUCE
INTERFRACTION ERRORS
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SETUP CORRECTIONS

Grey
Protocol offline matching

Offline
review
Week 3 Week 5

Day 1
S+I
Gross error

Week 2 Week 4 Week 6

Correction
Systematic
error

TREATMENT
 image--guided
Figure 2 Comparison of residual errors for different image
correction techniques in treatment of lung tumors.
VERIFICATION
CBCT & ABC
VERIFICATION
CBCT & ABC
VERIFICATION
CBCT
 VERIFICATION
CBCT

1ST #

Last #

Shape and size difference

 VERIFICATION
CBCT
CT SCAN
CBCT
LUNG COLAPSE
OAR???
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OAR

DAY 1 DAY X

AUTOMATIC MATCH NEW CENTRE

TUMOUR
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PROBLEMS WITH MOTION

SOLUTIONS

IGRT & ABC – LUNG

FUTURE
 FUTURE
Critical structure avoidance

Courtesy of Elekta
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CONCLUSION

o ABC to manage motion – reduce intrafraction motion

o IGRT - reduce interfraction motion

o Combined (CBCT & ABC) improve level of confidence and allow more

ambitious trials – better clinical outcomes

o Professionals have to update skills to be able to respond to the future

o Dose needed for CBCT is considerable smaller than for EPID

o Future – integration of technology (ABC, XVI and LINAC)

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Thank you for listening!

Acknowledgements
Helen McNair
Sarah Armstrong
All other staff