Chloe Pandeli

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Implementation of Gynaecological IMRT Planning

Technique – Clinical Guidelines and Constraints

Session Name: Proffered papers - Gastrointestinal / Gynaecological

• In accordance with the policy of The Royal Australian and New Zealand College of Radiologists, the Australian Institute of Radiography and the Australasian College of Physical Scientists and Engineers in Medicine the following presenter has indicated that they have a relationship which in the context of their presentation, could be perceived as a real or apparent conflict of interest but do not consider that it will influence their presentation. The nature of the conflict is listed:

• None

Session Name: Proffered papers - Gastrointestinal / Gynaecological

• The presenter has advised that the following presentation will NOT include discussion on any commercial products or service and that there are NO financial interests or relationships with any of the Commercial Supporters of the 2014 Combined Scientific Meeting.

Background

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• Endometrial cancer - 6th most common malignancy in women

- Most diagnosed at an early stage - Most patients aged over 60 years

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Patient Eligibility

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• Diagnosis of Endometrial cancer

• Post-operative RT recommended

• No gross residual disease

• No extensive serosal involvement of uterus, tubes or ovaries

• Patient able to comply with bladder and bowel preparation instructions

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Benefits of IMRT

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• Several advantages of IMRT compared to conventional radiotherapy - Less dose to OARs

• Clinical targets -Pelvic lymph nodes and vaginal vault

• OARs - Bladder - Rectum - Small bowel - Femoral head and neck

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Why implement IMRT?

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• Experienced staff • Available technology - Planning - Treatment

Implementation of IMRT for endometrial cancer at Epworth

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• Staff selected for implementation - RO, RTs, Physics, Nursing • Meetings with RO • Protocols for planning and treatment - Based on RTOG 0418 • Staff training

• Development of templates in eclipse

Patient care path

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• Initial appointment - RO consultation - RT discussion re bladder and bowel preparation

• Simulation appointment •Patient positioned supine with personalised vacfix •2 CT scans with vaginal contrast

- Empty bladder - Full bladder

Contouring

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•Guidelines based on RTOG 0418 protocol • Target volumes

-Nodal CTV & PTV -Vaginal ITV & PTV

•OARs • RT - Contours to assist with optimisation

Planning

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• 50.4 Gy in 28 Fx • 7 field IMRT technique (eclipse planning system) • 10MV photons • Dose constraints based on RTOG 0418 trial • Developed in-house templates and guidelines

IMRT vs. 4 field Conventional

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Patient 1 4 field IMRT

Small bowel (V40Gy ≤ 30%) 41.7% 22.03%

Rectum (V30Gy ≤ 60%) 79.2% 60.9%

Bladder (V45Gy ≤ 35%) 98.6% 45%

Femur R (V30Gy ≤ 15%) 36.0% 6.44%

Femur L (V30Gy ≤ 15%) 55.2% 4.99%

Patient 2 4 field IMRT

Small bowel (V40Gy ≤ 30%) 13.0% 3.3%

Rectum (V30Gy ≤ 60%) 97.4% 56.9%

Bladder (V45Gy ≤ 35%) 84.1% 23.5%

Femur R (V30Gy ≤ 15%) 60.0% 6.2%

Femur L (V30Gy ≤ 15%) 60.0% 7.5%

IMRT vs. 4 field

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Compromise

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•Difficulty maintaining bladder filling towards the end of treatment •2-5 fold increase in monitor units per treatment

Workload Implications

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• Increased time

- Simulation - Contouring - Planning - Physics QA - Treatment

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Conclusion

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• IMRT for endometrial cancer has been successfully implemented • Protocols and guidelines successfully adapted • Treatment well tolerated by patients • OARs receive lower doses than conventional RT • The expectation is that with longer follow up, our patients will record reduced late side effects • Preliminary outcomes - low toxicity rates and excellent pelvic control • Future considerations

- Use of fiducial markers - Dose escalation

Acknowledgements

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Dr. Bronwyn King ERO

References

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Ahamad A, Jhingran A, 2004 ‘New Radiation Techniques in gynecological cancer’ International Journal of Gynecological Cancer, 14:569-579 Harris E, Latifi K, Rusthoven C, Javedan K, Forster K, (2011) ‘Assessment of organ motion in postoperative endometrial and cervical cancer patients treated with intensity-modulated radiation therapy’ Int Journal of Radiation Oncology, Bio, Phys 81(4): e645-e650 Jhingran A, Winter K, Portelance L, Miller B, Salepour M, Gaur R, Souhami L, Small W, Berk L, Gaffney D, (2012) ‘A Phase II study of Intensity modulaed radiation therapy to the pelvis for postoperative patients with endometrial carcinoma: Radiation Therapy Oncology Group Trial 0418’, ’ Int Journal of Radiation Oncology, Bio, Phys 84(1): e23-e28 Roeske JC, Lujan A, Rotmensch J (2000) ‘Intensity modulated whole pelvis radiation therapy in patients with gynecologic malignancies’, Int Journal of Radiation Oncology, Bio, Phys 48:1613-1621 Salama K, Roeske J, Mehta N, Mundt A, (2004) ‘Intensity-modulated Radiation Therapy in Gynecologic Malignancies’ Current Treatment Options in Oncology, 5:97-108 Shih K, Milgrom S, Abu-Rustum N, Kollimer M, Gardiner G, Tew W, Barakat R, Alektiar K, (2013) ‘Postoperative pelvic intensity-modulated radiotherapy in high risk endometrial cancer’ Gynecologic Oncology 128: 535-539 Wagner A, Jhingran A, Gaffney D, (2013) ‘Intensity modulated radiotherapy in gynecologic cancers: Hope, hype or hyperbole’ Gynecologic Oncology 130: 229-236 Wright J, Medel B, Sehouli J, Fujiwana K, Herzog T, (2012) ‘Contemporary management of endometrial cancer’ The Lancet 379: 1352-1360 1) http://www.sswahs.nsw.gov.au/services/sgog/Corpus_Guide.html 2) http://www.pathologyoutlines.com/topic/uterusstaging.html 3) http://www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial-uterine-cancer-what-is-endometrial-cancer 4) http://radonc.ucsd.edu/patient-info/treatment-options/cancer-types/gynecologic-cancers/Pages/imrt.aspx 5) http://emmers712.blogspot.com.au/2011/12/wait-i-can-explain.html