Igrt Srt For Lung Cancer
-
date post
18-Oct-2014 -
Category
Health & Medicine
-
view
6.770 -
download
0
description
Transcript of Igrt Srt For Lung Cancer
![Page 1: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/1.jpg)
ImageImage--Guided and Guided and Stereotactic Radiotherapy Stereotactic Radiotherapy
(IGRT/SRT) for Lung (IGRT/SRT) for Lung CancerCancer
Gregory S. Sibley, M.D.Gregory S. Sibley, M.D.November 17, 2008November 17, 2008
![Page 2: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/2.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)TomotherapyTomotherapySpecific CaseSpecific Case
![Page 3: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/3.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)Specific Disease SitesSpecific Disease SitesTomotherapyTomotherapy
![Page 4: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/4.jpg)
Evolution of TechnologyEvolution of Technology
19701970’’s: Cobalts: Cobalt--60, treatment guided by 60, treatment guided by surgical anatomy and plain radiographs. Doses surgical anatomy and plain radiographs. Doses calculated from depthcalculated from depth--dose charts.dose charts.19801980’’s: Crosss: Cross--sectional imaging (CT) sectional imaging (CT) available to guide treatment delivery.available to guide treatment delivery.19901990--1995: 1995: ““HomeHome--growngrown”” 3D conformal 3D conformal radiotherapy planning systems appearing radiotherapy planning systems appearing allowing Beamallowing Beam’’s Eye Views Eye View
![Page 5: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/5.jpg)
![Page 6: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/6.jpg)
Evolution of TechnologyEvolution of Technology19951995--2000: Commercial 3D CRT planning 2000: Commercial 3D CRT planning systems available with routine adoption by systems available with routine adoption by most centers.most centers.1998: Sibley acquires 3D planning system.1998: Sibley acquires 3D planning system.19991999--2003: Patients routinely planned and 2003: Patients routinely planned and treated with 3D CRT and 3D dose calculation. treated with 3D CRT and 3D dose calculation. 2002: Sibley Cancer Center opens 11/02 with 2002: Sibley Cancer Center opens 11/02 with statestate--ofof--thethe--art digitally controlled linear art digitally controlled linear accelerators.accelerators.
![Page 7: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/7.jpg)
![Page 8: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/8.jpg)
ExternalExternal--Beam RadiotherapyBeam RadiotherapyPhoton energy 6Photon energy 6--23 MV23 MVFields collimated by Fields collimated by internal jawsinternal jawsFields shaped by internal Fields shaped by internal leaves (leaves (MLCMLC’’ss))Digital information transferDigital information transfer
![Page 9: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/9.jpg)
Evolution of TechnologyEvolution of Technology
2003: 5/03 first patient treated with Intensity2003: 5/03 first patient treated with Intensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)2004: CT scanner/simulator installed in Cancer 2004: CT scanner/simulator installed in Cancer CenterCenter2006: Gold 2006: Gold fiducialfiducial markers implanted markers implanted routinely for prostate cancer for Imageroutinely for prostate cancer for Image--Guided Guided Radiotherapy (IGRT)Radiotherapy (IGRT)2008: Tomotherapy with Stereotactic 2008: Tomotherapy with Stereotactic Radiotherapy capability (SRT)Radiotherapy capability (SRT)
![Page 10: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/10.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)Specific Disease SitesSpecific Disease SitesTomotherapyTomotherapy
![Page 11: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/11.jpg)
IntensityIntensity--Modulated RT Modulated RT (IMRT)(IMRT)
Requires exacting definition of target Requires exacting definition of target structures and use of definitions: GTV, CTV, structures and use of definitions: GTV, CTV, PTVPTV
GTV: Gross tumor volumeGTV: Gross tumor volumeCTV: Clinical target volume = region at risk for CTV: Clinical target volume = region at risk for subclinicalsubclinical spreadspreadPTV: Planning target volume = margin added for PTV: Planning target volume = margin added for setup uncertaintysetup uncertainty
![Page 12: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/12.jpg)
IMRT: IntensityIMRT: Intensity--Modulated RTModulated RT
Treatment typically delivered through five or seven Treatment typically delivered through five or seven beams with multiple segments treated to various beams with multiple segments treated to various intensities (i.e. intensity modulated)intensities (i.e. intensity modulated)End result is a dose distribution that closely matches End result is a dose distribution that closely matches requestrequestRequires expert physicians, expert physicists, Requires expert physicians, expert physicists, expensive technology and significant amounts of timeexpensive technology and significant amounts of time
![Page 13: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/13.jpg)
IMRTIMRT
![Page 14: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/14.jpg)
Radiation OncologyRadiation OncologyIMRT Treatments
0 0 0 0
837
2184
3104
5500
0
1000
2000
3000
4000
5000
6000
1999 2000 2001 2002 2003 2004 2005 2006
Year
![Page 15: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/15.jpg)
IMRT IMRT vsvs 3D: 3D plan3D: 3D plan
![Page 16: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/16.jpg)
IMRT IMRT vsvs 3D: IMRT plan3D: IMRT plan
![Page 17: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/17.jpg)
IMRT IMRT vsvs 3D: 3D: DVHDVH’’ss
GTV
Esophagus
Lung
![Page 18: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/18.jpg)
IMRT Appropriate Patient?IMRT Appropriate Patient?
![Page 19: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/19.jpg)
IMRT Appropriate Patient?IMRT Appropriate Patient?
![Page 20: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/20.jpg)
IMRT clearly helpsIMRT clearly helps
IMRT: dashed line
3DCRT: solid line
Esophagus
Tumor
![Page 21: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/21.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)Specific Disease SitesSpecific Disease SitesTomotherapyTomotherapy
![Page 22: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/22.jpg)
IGRT: ImageIGRT: Image--Guided RTGuided RTDaily targeting of internal structures instead of Daily targeting of internal structures instead of skin marks or bony landmarks.skin marks or bony landmarks.PerformedPerformed since 2006 by since 2006 by us for all prostate us for all prostate cancers by using gold cancers by using gold ““fiducialfiducial”” seeds.seeds.Trilogy and Tomotherapy are technologies that Trilogy and Tomotherapy are technologies that provide daily provide daily ““CTCT--like imageslike images”” that are matched that are matched to planning CT images for positioning.to planning CT images for positioning.New standard for stateNew standard for state--ofof--thethe--art radiotherapyart radiotherapy
![Page 23: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/23.jpg)
IGRT IGRT -- LungLung
![Page 24: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/24.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)Specific Disease SitesSpecific Disease SitesTomotherapyTomotherapy
![Page 25: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/25.jpg)
Stereotactic Radiotherapy (SRT)Stereotactic Radiotherapy (SRT)
Initially used only for cancers and disorders in Initially used only for cancers and disorders in the brain.the brain.Stereotactic Body Radiotherapy (SBRT) uses Stereotactic Body Radiotherapy (SBRT) uses similar concepts to treat cancers outside of the similar concepts to treat cancers outside of the brain.brain.SRT is SRT is notnot radiotherapy. One to five very large radiotherapy. One to five very large doses are used to doses are used to ““killkill”” everything within the everything within the defined target, i.e. radiosurgery.defined target, i.e. radiosurgery.
![Page 26: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/26.jpg)
SRT MachinesSRT Machines
Trilogy is a modified Trilogy is a modified linaclinac that delivers SRT through that delivers SRT through setup and monitoring with a kV imager.setup and monitoring with a kV imager.CyberKnife is a dedicated SRT machine that is not CyberKnife is a dedicated SRT machine that is not designed to provide radiotherapy capability. Small, designed to provide radiotherapy capability. Small, precise beams and long treatment delivery times.precise beams and long treatment delivery times.Tomotherapy is a Tomotherapy is a linaclinac that images and delivers that images and delivers treatment through a rotational gantry (like CT). treatment through a rotational gantry (like CT). Provides image guidance with every treatment and Provides image guidance with every treatment and can simultaneously treat multiple targets quickly.can simultaneously treat multiple targets quickly.
![Page 27: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/27.jpg)
Trilogy (Varian)Trilogy (Varian)
![Page 28: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/28.jpg)
CyberKnifeCyberKnife
![Page 29: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/29.jpg)
TomotherapyTomotherapy
![Page 30: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/30.jpg)
OutlineOutline
Evolution of TechnologyEvolution of TechnologyIntensityIntensity--Modulated Radiotherapy (IMRT)Modulated Radiotherapy (IMRT)ImageImage--Guided Radiotherapy (IGRT)Guided Radiotherapy (IGRT)Stereotactic Radiosurgery (SRS)Stereotactic Radiosurgery (SRS)TomotherapyTomotherapySpecific Disease SitesSpecific Disease Sites
![Page 31: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/31.jpg)
HIHI--ART Tomotherapy UnitART Tomotherapy UnitLinac
Pulse FormingNetwork andModulator
DetectorBeam StopHigh VoltagePower Supply
ControlComputer
Magnetron
Data Acquisition System
Circulator
Gun Board
![Page 32: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/32.jpg)
TomoTherapyTomoTherapy Advantages Advantages
•No Gantry-Patient Collision•No Wedges•No Gantry Angles•No Collimator Angles•No Table Angles•No Hand Pendants•No MLC Shapes or Coordinates•No MLC Motors•No Field/Jaw size•No Field Light•No Electrons•No Electron Cones
![Page 33: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/33.jpg)
ImageImage--guided Therapy: Principlesguided Therapy: Principles
Image guidance ensures that relative Image guidance ensures that relative positions of positions of isocenterisocenter and target are the and target are the same during treatment and in treatment same during treatment and in treatment planplanThis potentially allows:This potentially allows:
Reduced treatment margins Reduced treatment margins Increased doseIncreased doseReduced complicationsReduced complicationsAvoid missesAvoid misses
![Page 34: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/34.jpg)
Courtesy of University of Wisconsin
CT and VRCT Image sets using same window and
level adjustments
CT VRCT 2cGy
Image 1
Image 2
Image 3
Image 4
![Page 35: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/35.jpg)
Esophagus IGRTEsophagus IGRTAfter 2400cGy (12 After 2400cGy (12 FxFx))
Original Planning CT CT of the day (TomoImage)
Courtesy: Dr. Dan Petereit M.D., Rapid City Regional Hospital T-MKT-AP0068
![Page 36: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/36.jpg)
Stereotactic Radiotherapy Stereotactic Radiotherapy (SRT) (SRT)
for Stage I Nonfor Stage I Non--small Cell small Cell Lung CancerLung Cancer
![Page 37: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/37.jpg)
SBRT for Stage I LungSBRT for Stage I LungInstitutionInstitution # Patients# Patients Local Control Local Control YamanishiYamanishi, Japan, Japan 257257 86%* (92%)86%* (92%)JapanJapan 131131 96%96%Aarhus (Denmark)Aarhus (Denmark) 8989 89%89%Wash UWash U 7070 83%83%Indiana U (protocol)Indiana U (protocol) 7070 88%88%Cleveland ClinicCleveland Clinic 9494 97%97%AmsterdamAmsterdam 206206 97%97%
![Page 38: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/38.jpg)
StereotacticStereotactic-- The PatientThe Patient
![Page 39: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/39.jpg)
SRTSRT-- The SimulationThe Simulation
4D4D--CT simulation is performed (3D plus CT simulation is performed (3D plus motion). 36 motion). 36 multislicemultislice CT synchronized with CT synchronized with chest tension belt provides images at each chest tension belt provides images at each phase of respiration.phase of respiration.Abdominal pressure plate added (when Abdominal pressure plate added (when needed) to limit respiratory motionneeded) to limit respiratory motionGating utilized (when needed) for excessive Gating utilized (when needed) for excessive motionmotion
![Page 40: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/40.jpg)
SRTSRT-- The ImmobilizationThe Immobilization
![Page 41: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/41.jpg)
Stereotactic Radiosurgery (SRS)Stereotactic Radiosurgery (SRS)
Requires exacting immobilization and targetingRequires exacting immobilization and targetingFiducialFiducial markers not required with markers not required with TomoTherapyTomoTherapy
![Page 42: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/42.jpg)
StereotacticStereotactic-- The The TomoTomo PlanPlan
![Page 43: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/43.jpg)
StereotacticStereotactic-- The SetupThe Setup
![Page 44: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/44.jpg)
![Page 45: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/45.jpg)
![Page 46: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/46.jpg)
![Page 47: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/47.jpg)
![Page 48: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/48.jpg)
![Page 49: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/49.jpg)
StereotacticStereotactic-- Ready to TreatReady to Treat
![Page 50: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/50.jpg)
SRTSRT-- The TreatmentThe Treatment
Many fractionation schedules have been used, Many fractionation schedules have been used, but the but the ““winningwinning”” regimensregimens……20 20 GyGy x 3 = 60 x 3 = 60 GyGy12 12 GyGy x 4 = 48 x 4 = 48 GyGy (near sensitive structures)(near sensitive structures)
![Page 51: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/51.jpg)
SRTSRT-- ComplicationsComplications
Emerging treatment with paucity of longEmerging treatment with paucity of long--term term data, butdata, but……Peripheral lesions: develop rib fractures in Peripheral lesions: develop rib fractures in 13/31, 9/42, 3/131, 9/8613/31, 9/42, 3/131, 9/86Apical lesions: (Apical lesions: (3737/273 pts at IU, 89% LC) 7/37 /273 pts at IU, 89% LC) 7/37 developed developed grgr 22--4 brachial 4 brachial plexopathyplexopathy (1 hand (1 hand paralysis)paralysis)Misc: Misc: bronchovascularbronchovascular fistula, fistula, pneumonitispneumonitisMultiMulti--inst study: 11/70 inst study: 11/70 GrGr 33--5 toxicity 5 toxicity
![Page 52: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/52.jpg)
PotentialPotentialNew Clinical New Clinical
Opportunities:Opportunities:
ReRe--treatment for patientstreatment for patientsnot eligiblenot eligible
for radiation therapy for radiation therapy before before TomoTherapyTomoTherapy due to due to
cord tolerancecord tolerance
Patients courtesy Patients courtesy of University of of University of AlabamaAlabama
![Page 53: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/53.jpg)
SRS-Applications
Highly effective and time efficientMost common sites: brain, spine, lung, liverUseful for recurrent tumors in previously irradiated fieldsTumor control is seen in 80-90% of metastases treated, but survival is not impactedCurative for Stage I lung cancers…new standard of care for medically inoperable patients
![Page 54: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/54.jpg)
Summary
Image-Guided Radiotherapy is new gold standard for radiotherapyTomotherapy is elegant solution for IGRT and works well “out of the box”Stereotactic Radiosurgery is effective and time efficient method of palliationTomoTherapy delivers SRS as well, without need for fiducial markers
![Page 55: Igrt Srt For Lung Cancer](https://reader034.fdocuments.us/reader034/viewer/2022051311/54435637afaf9ff3098b4959/html5/thumbnails/55.jpg)
The EndThe End