Maria do Carmo Lopes, Tiago Ventura, Miguel Capela IPOCFG ... · ICARO 2, Vienna, Austria, 20-23 June 2017 Maria do Carmo Lopes, IPOCFG, Coimbra, Portugal TOMO-RADIOSURGERY: What

Maria do Carmo Lopes, IPOCFG, Coimbra, PortugalICARO 2, Vienna, Austria, 20-23 June 2017

TOMO-RADIOSURGERY: What do we gain, what do we lose comparing to Linac based SRS?

Maria do Carmo Lopes, Tiago Ventura, Miguel CapelaIPOCFG, E.P.E., Coimbra, PORTUGAL


1. RADIOSURGERY at IPOCFG – different phases and experience

2. TOMO-RADIOSURGERY vs. LINAC BASED SRS – a planning study

3. TOMO-RADIOSURGERY - what do we gain, what do we lose?

OUTLINE


Cones

1996-2003

Conformal Dynamic Arcs- micro-MLC

2008 - 2016

Localizing system from Fischer-Liebinger

Since Nov. 2016

RADIOSURGERY at IPOCFG

Tomotherapy (IMRT)


Fame fixation

Planning CT acquisition

Micro-MLC positioning and machine QA

Structures delineation and treatment planning

Patient localization and treatment

LINAC BASED SRS – Steps of the procedure


Metástase65%

Neurinoma16%

Meningioma6%

Adenoma4%

MAV5% Outro

2%

498 Lesions

Metástase

Neurinoma

Meningioma

Adenoma

MAV

Cavernoma

Glioblastoma

Outro

LINAC BASED SRS – Total number of treated lesions


240 Metastases study (2014)

Lesions

104 1

43 2

11 3

3 4

1 5

11 1+1

1 2+2

1 1+1+1

2 1+2

1 1+3

1 2+3

Total 240

46%

25%

6%

10%

3%10%

Primary pathology

Pulmão

Mama

Melanoma

Coloretal

Gástrico

Outro

64%

26%

7%

2%

1%

Nº of lesions- 240; Nº of patients- 162

1

2

3

4

5


22%

73%

240 Metastases study (2014)

Andrews DW et al., 2014, Lancet

Minniti G et al, 2011, Rad. Onc.

Molenaar R et al, 2009, J.Neurosurg.


TOMOTHERAPY (Since April 2016)


TOMO-SRS (2005 – 2010)


During the last decade…


HYPERARC (Varian) Dynamic Wave Arc (VERO)

Or even…


• 26 treated cases• 6 groups of lesions:

• GROUP I - VPTV > 7 cm3

• GROUP II - 3cm3< VPTV < 7 cm3

• GROUP III - 1cm3< VPTV < 3 cm3

• GROUP IV - VPTV < 1 cm3

• GROUP V – Close to brainstem

• GROUP VI - Neurinomas

A planning study


TOMO - Normal TOMO - High

Group II


V50%/V100% V20%/V100% V20%/V50%

HIGH 3,642 16,005 4,389NORMAL 4,692 19,817 4,221iPlan 3,002 9,776 3,249HIGH 4,756 23,761 5,031NORMAL 6,671 31,332 4,740iPlan 3,504 11,685 3,332HIGH 6,310 33,350 5,278NORMAL 8,631 44,213 5,098iPlan 4,246 15,086 3,550

HIGH 8,931 44,343 4,935NORMAL 12,238 57,776 4,670iPlan 5,400 18,855 3,488HIGH 5,012 27,620 5,483NORMAL 5,723 34,035 5,926iPlan 7,172 24,642 3,526HIGH 6,384 36,401 5,700NORMAL 8,106 45,910 5,659iPlan 4,611 17,290 3,740

GROUP IVPTV> 7 cc

GROUP II3< VPTV< 7 cc

GROUP III1< VPTV> 3 cc

GROUP IVVPTV< 1cc

GROUP VClose to

brainstem

GROUP VINeurinoma

GRADIENT INDEXES


0

2

4

6

8

10

12

14

Grupo I Grupo II Grupo III Grupo IV Grupo V Grupo VI

HIGH

NORMAL

iPlan

GRADIENT INDEX - GIIan Paddick, M.SC., and Bodo Lippitz, M.D. , J Neurosurg (Suppl) 105:194–201, 2006, A simple dose gradient measurement tool to complement the conformity index

Wilcoxon signed rank test for paired samples:Stat. signif. dif. between both NORMAL/HIGH and iPlan; also between NORMAL and HIGH


CONFORMITY INDEX - COIN

0,000

0,100

0,200

0,300

0,400

0,500

0,600

0,700

0,800

0,900

1,000

Group I Group II Group III Group IV Group V Group VI

HIGH

NORMAL

iPlan

V>7cc 3<V<7cc

1<V<3cc V<1cc Neurinomas

Close to Brainstem

Lomax NJ, Scheib SG. (2003) Quantifying the degree of conformity in radiosurgery treatment planning. Int J Radiat Oncolo Biol Phys. 55:1409-Van’t Riet A, et al.(1997) A conformation number to quantify the degree of conformality (…). Int J Radiat Oncol Biol Phys 37(3): 731-736Baltas D,, et al. (1998) A conformal index (COIN) (…). Int J Radiat Oncol Biol Phys. 40(2): 515-524

Wilcoxon signed rank test for paired samples:Stat. signif. dif. between both NORMAL/HIGH and iPlan; NS between NORMAL and HIGH


Dmin

82,0

84,0

86,0

88,0

90,0

92,0

94,0

96,0

98,0

100,0

Group I Group II Group III Group IV Group V Group VI

HIGH

NORMAL

iPlan

V>7cc 3<V<7cc 1<V<3cc V<1ccNeurinomas

Close to Brainstem

Wilcoxon signed rank test for paired samples:Statistically significant differences between NORMAL and iPlan (p<10-5 )


TOMOTHERAPY (Since April 2016)


TOMO-SRS


TOMO SRS – Steps of the procedure

Mouth mold execution

Treatment planning

Patient specific QA

Image acquisition and structures delineation

Localization, IGRT andTreatment


TOMO-SRS

• 1 patient in ONCOR – 10 fractions• 2 doentes in TOMO – 10 fractions• 2 doentes em TOMO – 3 fractions• …• 1st patient in TOMO – 1 fraction !


FRAMELESS OPTION – Previous Immobilization study

TOMO-SRS – Intrafraction immobilization accuracy

-3

-2

-1

0

1

2

3

0 5 10 15 20 25 30

Tran

slat

ion

al (

mm

)

Lesion number

Lateral

Longitudinal

Vertical

(0,0±-0,3)

(-0,1±-0,5)

(0,0±-0,4)



WHAT DO WE LOSE?• Conformity of low doses (steep dose gradients)• Based frame immobilization

WHAT DO WE GAIN?• IGRT with MVCT• Possibility to treat/plan in different days• Better conformity for irregular lesions even close to critical structures• Better target coverage (higher minimum dose)

WHAT IS COMPARABLE?• Total treatment time (?) – it depends on the number and lesions localization…• Patient confort ????

CONCLUSIONS: TOMO-SRS


6 weeks later

TOMO-SRS – first patient on November 11, 2016(already 35 treated lesions in 24 patients)


6 weeks later

TOMO-SRS – first patient on November 11, 2016(already 35 treated lesions in 24 patients)


Acknowledgement to:Tania Santos for the statistics analysis


Documents

Maria do Carmo Lopes, Tiago Ventura, Miguel Capela IPOCFG ... · ICARO 2, Vienna, Austria, 20-23 June 2017 Maria do Carmo Lopes, IPOCFG, Coimbra, Portugal TOMO-RADIOSURGERY: What