Gregoire H&N
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Transcript of Gregoire H&N
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
The “academic” view point
The “academic” view point
ICRU report 62, 1999
• Gross Tumor Volume: GTV
• Clinical Target Volume: CTV
• Planning Target Volume: PTV
Target volumes in Radiation Target volumes in Radiation OncologyOncology::ICRU ICRU definitiondefinition
ll 15 head & neck tumors15 head & neck tumorsll 15 brain tumors15 brain tumorsll 3 different masks (3, 4 & 5 FP) 3 different masks (3, 4 & 5 FP) ll 3 fictitious 3 fictitious isocentersisocenters
Immobilization of Immobilization of Head & Neck patientsHead & Neck patients
ll 915 portals images acquired.915 portals images acquired.ll 98 %98 % analysedanalysed..
ll Total Displacement.Total Displacement.uu SIM SIM -- EPIDEPIDii
ll Systematic Displacement.Systematic Displacement.uu M(SIM M(SIM -- EPIDEPIDii))
ll Random Displacement.Random Displacement.uu (SIM (SIM -- EPIDEPIDii) ) -- [ M(SIM [ M(SIM --
EPIDEPIDii)])]
ll IntraobserverIntraobserver variation:variation:0.7 mm (10.7 mm (1 SdSd).).
Immobilization of Head & Neck patientsImmobilization of Head & Neck patients
0.00.10.20.30.40.50.60.70.80.91.0
0 1 2 3 4 5 6 7 8 9 10Deviation from the isocenter (mm)
Cum
ulat
ive
inci
denc
eHead
(3-5 FP) Total 3Total 3--DDdeviationsdeviations
0.00.10.20.30.40.50.60.70.80.91.0
0 1 2 3 4 5 6 7 8 9 10Deviation from the isocenter (mm)
Cum
ulat
ive
inci
denc
e
Neck(3-5 FP)
00.10.20.30.40.50.60.70.80.9
1
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14Deviation of the isocenter (mm)
Cum
ulat
ive
inci
denc
e Shoulder(4 & 5 FP)
Characteristics of currentCharacteristics of currentimaging modalitiesimaging modalities
CT MRI PET fMRIImage characteristics
skin contour + ± ± -soft-tissue contrast ± + - -bone contrast + ± - -air contrast + ± ± -metallic artefacts + ± - ±movement artefacts - + ± +
Machine characteristicslarge “tunnel” size + - - -distortion - + ± +electron density + - ± -multiplannar imaging - + ± +
Image acquisitionImage acquisition
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
• Dual detector spiral CT
• 2.7 mm collimation, pitch 0.7, reconstruction of 2 - 2.5 mm
• Display matrix of 512 x 512 pixels
• Contrast enhancement (interstitial and blood vessel contrast)
Conformal radiotherapy:reference coordinates
Conformal radiotherapy:3D reconstruction
Conformal radiotherapy:3D reconstruction
Conformal radiotherapy:image display
Cervical lymph node groups(MSKCC classification)
Adopted by the Academy’s Committee for Head & Neck Surgery and Oncology
Robbins et al, 1991
The The presentpresent … … which which CTV for the neck ?CTV for the neck ?
State of the art
• Predictive pattern of lymph node involvement in HNSCC
• Selective neck treatment (irradiation or dissection) for selected N stage
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Definition of the extend of the CTV in the neck
IIIV
III
Ia
Ib
II
Ia
Ib
The present …CT-based delineation oflymph node levels in the neck
Grégoire et al., 2000
Ia
Ib
II
RP
VI
VIII
Conformal radiotherapy:volume delineation
Conformal radiotherapy:volume delineation
Conformal radiotherapy:Beam selection
BEV
Conformal radiotherapy:Dose distribution
Conformal radiotherapy:Dose distribution
Conformal radiotherapy:Dose volume histogram
Conformal radiotherapy:Dose volume histogram
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01)
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Mr H. D. (77 years): T3-N0-M0 base of tongue (ICD0-10: C01)
Target volumesTarget volumes• T: CTV1: GTV + 1.5 cm margin
CTV2: GTV + 0.5 cm marginPTV1&2 : CTV + 4 mm
• N:CTV: R & L LII - IVPTV: CTV + 4 mm
Dose prescriptionDose prescription• T: PTV1: 50 Gy, 25x2 Gy
PTV2: 70 Gy, 35x2 Gy• N:PTV: 50 Gy, 25x 2Gy
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Rx 6 MV40 Gy
Rx 6 MV30 Gy
Rx 6 MV50 Gy
Elect 8 MeV10 Gy
“Antique”(7 fields)
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
PTV 55 GyDmean 63.2 60.1 59.2Dmax 79,1 76.6 74.6Dmin 10.0 39.1 44.4SD 10.2 9.5 8.1
PTV 70 GyDmean 72.4 71.7 70.6Dmax 76.9 76.5 74.6Dmin 67.4 65.2 67.0SD 1.8 2.1 1.5
L parotidDmedian 68.7 52.1 50.7Dmax 72.8 72.5 71.8Dmin 46.4 8.4 5.4SD 7.6 12.2 15.5
R parotidDmedian 69.6 65.7 40.6Dmax 72.9 72.6 55.9Dmin 62.1 4.4 3.6SD 1.7 24.9 16.7
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
Spinal cordDmean 22.8 19.6 22.7Dmax 43.0 41.9 47.6Dmin 5.5 3.3 2,7SD 16.0 16.1 18.0
MandibulaDmedian 71.5 68.9 60.5Dmax 76.8 74.5 72.2Dmin 51.1 4.8 3.7SD 2.2 22.0 17.4
Internal contourDmedian 41.6 13.6 19.3Dmax 79.2 76.6 74.6Dmin 2.0 1.2 1.1SD 21.5 23.4 22.2
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
“Middle Age”(9 fields)
Rx 6 MV40 Gy
Rx 6 MV20 Gy
Rx 6 MV50 Gy
Rx 6 MV10 Gy
Elect 8 MeV10 Gy
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
“Middle Age”(9 fields)
Rx 6 MV40 Gy
Rx 6 MV20 Gy
Rx 6 MV50 Gy
Rx 6 MV10 Gy
Elect 8 MeV10 Gy
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
PTV 55 GyDmean 63.2 60.1 59.2Dmax 79,1 76.6 74.6Dmin 10.0 39.1 44.4SD 10.2 9.5 8.1
PTV 70 GyDmean 72.4 71.7 70.6Dmax 76.9 76.5 74.6Dmin 67.4 65.2 67.0SD 1.8 2.1 1.5
L parotidDmedian 68.7 52.1 50.7Dmax 72.8 72.5 71.8Dmin 46.4 8.4 5.4SD 7.6 12.2 15.5
R parotidDmedian 69.6 65.7 40.6Dmax 72.9 72.6 55.9Dmin 62.1 4.4 3.6SD 1.7 24.9 16.7
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
Spinal cordDmean 22.8 19.6 22.7Dmax 43.0 41.9 47.6Dmin 5.5 3.3 2,7SD 16.0 16.1 18.0
MandibulaDmedian 71.5 68.9 60.5Dmax 76.8 74.5 72.2Dmin 51.1 4.8 3.7SD 2.2 22.0 17.4
Internal contourDmedian 41.6 13.6 19.3Dmax 79.2 76.6 74.6Dmin 2.0 1.2 1.1SD 21.5 23.4 22.2
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Rx 6 MV 50 Gy
“Art nouveau” (10 fields, 12 segments )
Ant.RPO LPO
SRAO SLAO
…
Post. Seg. 1 Post. Seg. 2
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Rx 6 MV 20 Gy
“Art nouveau” (11 fields, 12 segments )
Ant. RAO LPO
LAO1 LAO2
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
PTV 55 GyDmean 63.2 60.1 59.2Dmax 79,1 76.6 74.6Dmin 10.0 39.1 44.4SD 10.2 9.5 8.1
PTV 70 GyDmean 72.4 71.7 70.6Dmax 76.9 76.5 74.6Dmin 67.4 65.2 67.0SD 1.8 2.1 1.5
L parotidDmedian 68.7 52.1 50.7Dmax 72.8 72.5 71.8Dmin 46.4 8.4 5.4SD 7.6 12.2 15.5
R parotidDmedian 69.6 65.7 40.6Dmax 72.9 72.6 55.9Dmin 62.1 4.4 3.6SD 1.7 24.9 16.7
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Dose (Dose (GyGy) at various organs at risk) at various organs at riskAntique Middle-age Art nouveau
Spinal cordDmean 22.8 19.6 22.7Dmax 43.0 41.9 47.6Dmin 5.5 3.3 2,7SD 16.0 16.1 18.0
MandibulaDmedian 71.5 68.9 60.5Dmax 76.8 74.5 72.2Dmin 51.1 4.8 3.7SD 2.2 22.0 17.4
Internal contourDmedian 41.6 13.6 19.3Dmax 79.2 76.6 74.6Dmin 2.0 1.2 1.1SD 21.5 23.4 22.2
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Forward planning IMRT
• « human optimization »
Inverse planning IMRT
• Dose-volume constraints & weights for PTV and OARs
• optimization algorithms
• Penalty function
ll Spare cordSpare cordll Spare left parotid Spare left parotid ll 15 segments15 segmentsll 10 levels10 levels
1 6.Cummulative % of MUsSegment #
Courtesy of C. Field
Inverse planning IMRT for Inverse planning IMRT for Head and Neck TumorsHead and Neck Tumors
Inverse planning IMRT for Inverse planning IMRT for Head and Neck TumorsHead and Neck Tumors
PTV
Spared parotid gland
Courtesy of C. Field
Parotid Parotid gland gland functionfunction
lemonjuice
370 MBq 99mTc-pertechnetate
Parotid Parotid gland gland functionfunctionObjective assessment
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Bilateral irradiationUnilateral irradiation
R= 0,77M
axim
um s
ecre
tion
(%)
Mean parotid dose (Gy)
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Duration of treatment planning procedure
2D planning Forward planning Inverse planning(St-Luc) (Edmonton Cancer center)
Volume delineation 0 - 0.25h 2 - 3h 1 - 1.5h
Planning 0.25h 2 - 8h 1 - 2h
Individualized QC 0h 0.25h 1h
Treatment (per session) 10 - 15 min 20 - 25 min 15 min
State of the art
• Predictive pattern of lymph node involvement in HNSCC
• Selective neck treatment (irradiation or dissection) for selected N stage
Conformal radiotherapy and IMRTConformal radiotherapy and IMRTin Head and Neck Tumorsin Head and Neck Tumors
Definition of the extend of the CTV in the neck