the real time image guided hdr brachytherapy for prostate

The Real Time Image Guided HDR Brachytherapy for Prostate Cancer.

Treatment Planning

Bashar Al-Qaisieh

Bashar.Al-Qaisieh@leedsth.nhs.uk

Treatment Planning Objectives:

Delivery of prescription dose to target volume and minimise dose to nearby

normal tissues

Bashar.Al-Qaisieh@leedsth.nhs.uk

Prostate HDR Treatment Planning Involves:

• Pre-treatment QA:- equipment functionality and connectivity

• Patient setup:- measurement of US probe and template position with respect to patient

• Needle Insertion:- optimal position

• Contouring:- position of applicators with respect to PTV and OAR

• Dosimetry Planning:- needle reconstruction- source activation- optimisation

Bashar.Al-Qaisieh@leedsth.nhs.uk

Patient Setup

• Position of the US probe in the stepper unit

• Position of template with respect to the US probe

• Position of anatomy with respect to the template and US probe

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual”, “Live” & “Post” Operation Functions

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Image Capture- Set Base

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Image Capture

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Contouring

• Option 1:- Contour Prostate, Urethra, Rectum

- Utilise to produce a “virtual” plan- Utilise at later stages after needle insertion

• Option 2:- Calculate volume estimate from H,W,L measurement (SJIO)

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Contouring- Option 1

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Contouring- Option 2HWL Volume Estimate

0

10

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15 20 25 30 35 40 45

Virtual height (mm)

Live

hei

ght (

mm

)

0

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60

70

25 30 35 40 45 50 55

Virtual width (mm)Li

ve w

idth

(m

m)

Regression line

Recorded live width

95%

90%

85%

80%

0

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20 25 30 35 40 45 50 55 60

Virtual length (mm)

Live

len

gth

(mm

)

Regression line

Recorded live length

95%

90%

85%

80%

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Contouring- Option 2

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion

• Option 1:- Forward

- Manual and Geometric- SJIO

• Option 2:- Inverse

- HIPO

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 1:Forward

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 1:Forward SJIO

• Reference transverse plane for peripheral needles

• Base and Apex for middle needles

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 1:Forward SJIO

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 1:Forward SJIO

• All needles inserted to same depth of at least 1.0cm beyond the base to account for needle dead end for metal needle 1 cm

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 2:HIPO

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Virtual” Needle Insertion-Option 2:HIPO

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Image Capture

• All needles pushed to at least 1.0 cm deep from the base.

• Needles Locked to the template.

• Take final base measurement

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Needle Tip Tracking

• All needle tips are updated at the same depth (base). Convert needles from “V” to “L”

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Needle Tip Tracking

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Image Capture

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Contouring Guidance

• Update “Virtual”contours to match “Live” image set

• Prostate dimension pre needle insertion

• Record of needle position with respect to the prostate as a surrogate

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Contouring and PTV Margins

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Contouring

Bashar.Al-Qaisieh@leedsth.nhs.uk

Needles Free Length measurement and “Live” Tracking

Measured

Recorded

TPS

Bashar.Al-Qaisieh@leedsth.nhs.uk

Needles “Live” Tracking

Bashar.Al-Qaisieh@leedsth.nhs.uk

“Live” Source Activation

Bashar.Al-Qaisieh@leedsth.nhs.uk

Planning Aims and Optimisation Options

• Prostate:– 15Gy=100% isodose– V100%>95%– V150%<45%– V200%<15%– D90>100%

• PTV:– V100%>95%

• Rectum:– D2cc<11.8Gy– V100%=0.0cc

• Urethra:– D10%<17.5Gy– D0.1cc<17.5Gy

Morton et al 2009, GEC-ESTRO 2013

Bashar.Al-Qaisieh@leedsth.nhs.uk

Inverse Optimisation-DVHO

Bashar.Al-Qaisieh@leedsth.nhs.uk

TG 43 Dose Calculation

0.5 1.0 1.5 2.0 2.5 3.00123456789

10

r

Dep

th D

ose

Distance (cm)

Bashar.Al-Qaisieh@leedsth.nhs.uk

Inverse Optimisation-DVHO

Bashar.Al-Qaisieh@leedsth.nhs.uk

DVH output

Bashar.Al-Qaisieh@leedsth.nhs.uk

Good Job…well done!!!

• Oncologist check• Approve plan• Print and transfer to treatment machine• Handover to physics to independent check• Handover to radiographers• Have a cup of coffee!!

Bashar.Al-Qaisieh@leedsth.nhs.uk

Timing According to Individual Planners

Planner (no cases) Time from probe in to patient

treated Needle

insertion Needle

reconstruction Planning

A (4) 02:22 00:24 00:14 00:10

B (4) 02:54 00:28 00:29 00:13

C (2) 02:54 00:38 00:16 00:24

D (7) 02:53 00:25 00:16 00:15

E (3) 02:52 00:36 00:21 00:14

Data from 20 implants- 2012

Bashar.Al-Qaisieh@leedsth.nhs.uk

Thank You