What do we Know About Adaptive...
Transcript of What do we Know About Adaptive...
![Page 1: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/1.jpg)
What do we Know About Adaptive Radiotherapy?
Lei Dong, Ph.D.Scripps Proton Therapy Center
San Diego, California
AAMD Region II MeetingHouston, Texas September 13-14, 2012
![Page 2: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/2.jpg)
![Page 3: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/3.jpg)
Learning Objectives
To gain a working definition of adaptive radiotherapy (ART);
To understand the technical and process components needed for adaptive therapy
To learn about different time scales (offline/online) for plan adaptation
![Page 4: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/4.jpg)
What is adaptive radiotherapy?
![Page 5: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/5.jpg)
Adaptive
![Page 6: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/6.jpg)
“Definition”"Adaptive radiotherapy" is defined as
changing the radiation treatment plan delivered to a patient during a course of radiotherapy to account for Temporal changes in anatomy (e.g. tumor
shrinkage, weight loss or internal motion) Changes in tumor biology/function (e.g.
hypoxia).
![Page 7: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/7.jpg)
“Definition”Adaptive radiotherapy requires that a
new radiation plan be made for the patient, and can occur at three different timescales: offline between fractions; online immediately prior to a fraction; in real time during a fraction.
![Page 8: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/8.jpg)
Conventional workflow
Treatment
Planning
Simulation
![Page 9: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/9.jpg)
Concept of Treatment PlanningGoal: To design a treatment plan based on an
anticipated patient treatment
- Requirements- Accurate model of the patient
- CT or 4DCT of the patient in treatment position
- Accurate margin prediction- Balance of risk and benefit
- Presentation of simulation results- DVHs, Isodose lines
![Page 10: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/10.jpg)
The initial simulation CT is perhaps the most biased representation of patient’s
anatomy!
![Page 11: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/11.jpg)
Dong/MDACC
Is one CT before treatment good enough for planning?
![Page 12: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/12.jpg)
Is one DVH enough to accept the plan?
KUPELIAN et al. IJROBP vol.66, pp876 (2006)
![Page 13: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/13.jpg)
90% of daily bladder volumes are smallerthan the volume at the simulation!
Time-Trend for Bladder Volume
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
0 7 14 21 28 35 42 49 56 63
Elapsed Days
Rat
io R
elat
ive
to S
imul
atio
n C
T
pat01pat02pat03pat04pat05pat06pat07pat08pat09pat10pat11pat12pat13pat14pat15
Frank et al. IJROBP71 (3):813-820, 2008.
![Page 14: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/14.jpg)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1000 2000 3000 4000 5000 6000 7000 8000 9000Dose (cGy)
% B
ladd
er V
olum
e
AveragePlanning
Bladder DVH Variations during Daily Treatment
Error bar (+/- 1SD) was calculated based on 24 serial CT images.
Plan
![Page 15: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/15.jpg)
Planning CT During Treatment
Significant Anatomic Variations
CTV is in the air!RTOG H0022 Case
![Page 16: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/16.jpg)
Original Proton PlanDose recalculated on the new anatomy
Bucci/Dong et al. ASTRO Abstract, 2007
Impact of Tumor Shrinkage on Proton Dose Distribution
![Page 17: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/17.jpg)
A single plan designed before treatment is
insufficient to describe the actual delivered doses,
and often leads to suboptimal treatment.
![Page 18: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/18.jpg)
What is IGRT and what can IGRT do?
![Page 19: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/19.jpg)
Essential Components for IGRT
Acquire an image inside a treatment roomAcquire the positional information of the target,
target surrogates, or avoidance structures Obtain “target” registration error
Rigid image registrationDetect positional deviations from the original plan
Perform an interventionMove the isocenter
![Page 20: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/20.jpg)
AJ Mundt/UCSD
![Page 21: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/21.jpg)
Planning CT Treatment CT
Planning Isocenter
Planning Contours
Treatment Isocenter
Treatment Image
Move Iso
Move Couch
r
r
Alignment Process
![Page 22: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/22.jpg)
What IGRT can’t do well?
![Page 23: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/23.jpg)
Change in the Neck Curvature
Planning CT
Daily Cone-beam CT with planning contour overlay
![Page 24: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/24.jpg)
Planning
Daily
Planning
Daily
Examples of anatomy rotation between the planning CT (first row) and the daily CT (second row). The axial CT images shown on the left indicate a roll in the patient’s head; the coronal CT images on the right show yaw (rotation of the spinal column).
![Page 25: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/25.jpg)
Patient with Tongue Base Carcinoma 19 CT Scans over 47 Days
ElapsedDays
Lei Dong et al. (MDACC)
Setup Uncertainties In Head & Neck Treatment
![Page 26: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/26.jpg)
Kranen et al., IJROBP, V73, pp1566 (2009)
Setup uncertainties in sub-regions of H&N anatomy
![Page 27: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/27.jpg)
Kranen et al., IJROBP, V73, pp1566 (2009)
Increased deformation with longer distances from the reference (C1-C3)
![Page 28: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/28.jpg)
Kranen et al., IJROBP, V73, pp1566 (2009)
Impact of ROI Selection for Patient Setup
![Page 29: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/29.jpg)
Planning CT 2 weeks into treatment
Target Volume Increases- Can’t be corrected by simple couch shifts
![Page 30: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/30.jpg)
Lee, C., K. M. Langen, et al. (2008). Int J Radiat Oncol Biol Phys 71(5): 1563-71.
![Page 31: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/31.jpg)
![Page 32: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/32.jpg)
Image guidance (to move isocenter) can’t not fully
correct for non-rigid changes
![Page 33: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/33.jpg)
Image Guidance vs. Adaptive RT
“Image Guidance” is commonly referred to a process to re-position the patient without modifying the initial treatment plan
Adaptive RT involves the modification of the initial plan, including Changing beam apertures or intensity
patterns Image-guidance and adaptive RT are
commonly used together
![Page 34: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/34.jpg)
ART and delivered dose evaluation
Final Dose
Daily Dose
Prospective Correction• Cumulating doses• Auto-segmentation via non-
rigid image registration• online/offline replanning
Retrospective Evaluation• Isodose line deformation• Cumulative calculation of true doses
![Page 35: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/35.jpg)
What is deformable (non-rigid) registration?
![Page 36: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/36.jpg)
Deformable Transformation
y
Fixed Image
Transform
x
y
Moving Image
x
Deformable image registration is a voxel mapping process
![Page 37: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/37.jpg)
What is deformable image registration?
Non-rigid Image Registration Finding the geometric correspondence of
the same point in two images.
Approaches Feature-based (control points, thin-plate
spline etc.) Model-based (finite element method etc.) Image-intensity based (optical flow,
diffusion method, free-form etc.)
![Page 38: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/38.jpg)
A Pictorial Tour of Deformable Image Registration
Radhe Mohan, Ph.D.Chairman of Radiation Physics
Bill GatesChairman of Microsoft
![Page 39: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/39.jpg)
Deformable image registration
Deformable image registration+
Image fusion
![Page 40: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/40.jpg)
Deformable image registration is an ill-defined problem
There is no unique solution (degeneracy) Similar voxels can be grouped differently
based on different rules. There is only one truth Usually we don’t know the ground-truth!
![Page 41: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/41.jpg)
Specifications for DIR Accurate (close to “real”) Topology reserved
Neighborhood relationship (connectivity, orientability etc.)
Robust (tolerance to variations) inconsistency in voxel intensities
Example: CT vs. CBCTExample: rectal gas
Fast (automated)
![Page 42: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/42.jpg)
Prostate Radiotherapy
Planning contours mapped to 24 in-room CTs
Wang H. et al. IJROBP 72 (1):210-219, 2008.
![Page 43: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/43.jpg)
upper
lower
upper lower
Planning contours were automatically transformed to subsequent 15 (daily) CT images
Head and Neck Case
Wang et al.
![Page 44: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/44.jpg)
4D CT Contour Propagation
Transverse Sagittal Coronal
Dong et al.
![Page 45: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/45.jpg)
Dong/MDACCTreatment Room
Treatment Planning
CT scanner CT-Simulation Treatmentplanning system
LINAC console
LINAC Patient couch CT-on-Rails
CT console AlignmentWorkstation
Console
On/OffOn/Off--linelineAdaptiveAdaptive
RadiotherapyRadiotherapy
A workflow diagram for in-room CT-guided adaptive radiotherapy
Adaptive ProtocolIRB # 2006-0947
![Page 46: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/46.jpg)
Study Goals Develop a practical procedure for IGART Evaluate the dosimetric benefits of a
hybrid (on-line image guidance + off-line adaptive) approach for head & neck radiotherapy
Evaluate clinical workflow and practical aspects of ART in a prospective trial
Evaluate the improvement in outcome
![Page 47: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/47.jpg)
Methods• 22 patients treated according to IRB-approved, NCI-supported clinical trial.• Stage III-IVa oropharyngeal SCCA.
• Functional QOL outcome measures• Baseline standard IMRT (3-mm PTV margins)
• 66Gy/30 (-CTX) or 70Gy/33 (+CTX); CTV1/2/3• Daily in-room CT-on-Rail imaging with IGRT• Weekly off-line plan re-evaluation• One (ART1) or two (ART2) adaptive replans
• 0-mm PTV margins
![Page 48: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/48.jpg)
Patient #2
BoneAlignment
Daily CT-guided C2-bone Setup
![Page 49: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/49.jpg)
Methods—IGRT vs. ART
![Page 50: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/50.jpg)
Methods• Compared 4 planning scenarios
• (1) the original IMRT plan aligned to the marked isocenter (BB)
• (2) the original plan aligned according to daily bone alignment (IGRT)
• (3) IGRT with one adaptive replan (ART1)• (4) actual treatment received (IGRT with one or
two adaptive replans, ART2). • Cumulative dosimetry was calculated by deformably mapping daily doses retrospectively back onto original plans.
![Page 51: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/51.jpg)
Adaptive Replanning• All cases underwent ART1• Elapsed time CT to ART: 1.7 days• Median 1st replan: 16th fraction• Mean parotid volume change at ART1: -16%• Mean CTV change at 1st replan: -5%• 8 (36%) cases underwent ART2
• Median start for the 2nd plan: 22nd fraction• Mean parotid volume change: -24%• Mean CTV change: -14%• Median start for the 1st plan: 11st fraction
![Page 52: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/52.jpg)
Timing of ART
Replanning Fraction #
![Page 53: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/53.jpg)
Early Adaptation – Fraction #1!Original Plan 1st Treatment Fraction
Pat No.L
![Page 54: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/54.jpg)
Early Replan – Fraction #1!Original Plan 1st Treatment Fraction
![Page 55: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/55.jpg)
Early Adaptive Replan Case
‐10%
‐5%
0%
5%
10%
15%
20%
25%
30%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
CTV70
CTV70
‐10%
‐5%
0%
5%
10%
15%
20%
25%
30%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
CTV63
CTV63
‐20%
‐10%
0%
10%
20%
30%
40%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
R Parotid
R Parotid
R Parotid
‐20%
‐10%
0%
10%
20%
30%
40%
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33
L Parotid
L Parotid
1st plan 2nd plan
CTVhigh CTVlow
L Parotid
0
![Page 56: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/56.jpg)
An Example
-40%
-30%
-20%
-10%
0%
10%
20%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
CTV70 % Change
CTV63 % Change
CTV57 % Change
Left Parotid % Change
Right Parotid % Change
Re-Plan1 Re-Plan2
![Page 57: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/57.jpg)
Solid – daily treatmentDash – Original Plan
Cumulative DVH after 33 fractions
Patient #1
![Page 58: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/58.jpg)
BB Alignment
Patient #4
Dotted – Org Plan
![Page 59: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/59.jpg)
Bone Alignment
Patient #4
Dotted – Org Plan
![Page 60: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/60.jpg)
Re-plan Once
Patient #4
Dotted – Org Plan
![Page 61: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/61.jpg)
Re-plan Twice
Patient #4
Dotted – Org Plan
![Page 62: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/62.jpg)
Early Conclusions
• IG-ART is feasible for H&N• IGRT alone does not provide meaningful dosimetric benefit if conventional PTV margins are used. • One properly timed adaptive replan (ART1) provided all relevant dosimetric improvements in this study.• Clinical outcomes continue to be collected.
![Page 63: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/63.jpg)
Is IG-ART ready for prime time?
![Page 64: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/64.jpg)
Practical Issues in Adaptive RT
Where do you find a physician to review your plan?
![Page 65: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/65.jpg)
Practical Issues in Adaptive RT
Record & Verification system slows the replanning process
Documentation requirements for new plan Billing?
![Page 66: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/66.jpg)
Other forms of adaptive RT
Anatomic = morphological the form and structure of organisms and their
gross structural features CT, T1-MRI?
Physiological = functional How organs or cell systems carry out the
chemical or physical functions in a living system
PET, T2-MRI, DCE MRI…
![Page 67: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/67.jpg)
ART – Modifying original prescription based on up-
to-date biological information of the target
![Page 68: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/68.jpg)
Emerging Biological/functional imaging for ART
C. Ling et al. IJROBP Vol. 47 No. 3 p551, 2000
![Page 69: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/69.jpg)
Role of Functional Imaging
![Page 70: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/70.jpg)
EARLY PREDICTION OF OUTCOME IN ADVANCED HEAD-AND-NECK CANCER BASED ON TUMOR BLOOD
VOLUME ALTERATIONS DURING THERAPY
Cao et al. IJROBP, Vol. 72, No. 5, pp. 1287–1290, 2008
Gained local control
Failed local control
Blood volume maps (DCE-MRI) after 2 weeks of RT
![Page 71: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/71.jpg)
Dose Painting By Numbers(More accurate imaging and targeting are required
for non-uniform dose prescriptions)
Brown SR et al. PMB 54 (2009) 1483–1501
![Page 72: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/72.jpg)
Functional Imaging is rarely tumor specific
Neither FDG nor FLT are tumor specific Nonspecific uptake has been seen with
virtually all PET tracers Particularly in post-radiation therapy
setting, the infiltration of FDG avid macrophages, inflammation, reactive lymph nodes,…
Image processing techniques from raw signals to biological signals
![Page 73: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/73.jpg)
Anatomy and Physiology are tied together
Anatomy, the study of form and structural features, and physiology, the study of function, are intrinsically tied.
Functional images must be fused with anatomical images to provide meaningful interpretation and quality assurance
A treatment plan must be calculated on a CT-equivalent anatomy
![Page 74: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/74.jpg)
Marcel van Herk (2008) “One should still realize that no form of biological
imaging is capable of showing tumor deposits that are small relative to the resolution of the scanners (which is, for instance, at best 5 mm for PET). This means that tumor deposits on a microscopicallevel cannot be visualized and may be missed, and moreover that dose painting based upon biological images showing radioresistant areas (i.ehypoxia) at a low resolution may be suboptimal. In addition, the complexity of the tumor biology makes the interpretation of molecular images far from trivial”
![Page 75: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/75.jpg)
Timing of Adaptive Radiotherapy
Image-guidance is a “near real-time” online isocenter correction method
Offline Adaptive Radiotherapy Minimum lag time is 1 day
Online Adaptive Radiotherapy Replanning and use the new plan for the
current treatment session
![Page 76: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/76.jpg)
Daily IGRT is very effective in correcting target positions
Is the center of tumor more important than the edge?
![Page 77: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/77.jpg)
TLE1
TRE1
TLE4
TRE4
TLE2
TRE2
TLE3
TRE3
TC
CTV0 CTVi
Illustration of Target Registration Error
Dong
![Page 78: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/78.jpg)
Boundary of target is more vulnerable than the center of target
PTV
Dong
![Page 79: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/79.jpg)
Early Replan – Fraction #1!Original Plan 1st Treatment Fraction
![Page 80: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/80.jpg)
![Page 81: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/81.jpg)
Requirements for Online ART
Fast imaging Fast target and normal tissue delineation Auto-planning Fast QA or real-time beam verification Intra-fractional management
Dong
![Page 82: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/82.jpg)
Is technology ever a bottleneck?
![Page 83: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/83.jpg)
SCORE: A GPU-based Re-planning System
for Online Adaptive Radiotherapy
Steve Jiang, Ph.D.
![Page 84: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/84.jpg)
![Page 85: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/85.jpg)
GPU based Online ART
Imaging and reconstruction: 1 min Target and normal tissue delineation: 10s Auto-planning: 1 min Fast QA or real-time verification: ?
![Page 86: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/86.jpg)
Online Adaptive ART Available Today!
![Page 87: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/87.jpg)
A X. Li (MCW)
![Page 88: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/88.jpg)
A X. Li (MCW)
![Page 89: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/89.jpg)
Benefits of Online Adaptive Radiotherapy
Correction for non-rigid anatomical changes beyond image guidance
Further improvement in conformality of the delivered plan Reducing margin requirements for IGRT Reducing normal tissue dose Dose-guided, instead of anatomy based Correction for acute biological changes
Dong
![Page 90: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/90.jpg)
Scoring Sheet
Problems IGRT OfflineART OnlineART
Daily target position
Systematic target shape
Systematic OAR shape
Daily target shape
Daily OAR shape
X
X
X
X
X
X
Dong
![Page 91: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/91.jpg)
Summary for Applications of ART Correct for deficiencies in the simulation
process Correct for non-rigid anatomical changes
beyond image guidance Further improve the conformality of the
delivered plan Creating better conformal treatments Reduce margin requirements for IGRT Reduce normal tissue dose by treating a
smaller target volume
![Page 92: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/92.jpg)
Adaptive Radiotherapy is a nature progress towards
truly personalized radiation medicine
Potential clinical gains outshine near-term difficulties
![Page 93: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/93.jpg)
ART and Teenage Sex
It is on everybody's mind all the time,
LD 05/09
Everyone is talking about it, Everyone thinks everyone else is doing it, Almost no one is really doing it, The few who are doing it are: Doing it poorly; Sure it will be better next time.
![Page 94: What do we Know About Adaptive Radiotherapy?brittanycheck.weebly.com/uploads/3/8/7/1/38715735/... · "Adaptive radiotherapy" is defined as changing the radiation treatment plan delivered](https://reader033.fdocuments.us/reader033/viewer/2022053017/5f1ce7dbbfd33878861454ae/html5/thumbnails/94.jpg)
Adaptive?