imrt: dal presente al futuro l’esperienza italiana
TRANSCRIPT
Ordine Mauriziano - IRCC, Torino
IMRT: IMRT: dal presente al futurodal presente al futuroLL’’esperienza italianaesperienza italiana
U.O.A. Fisica SanitariaOrdine Mauriziano
Reggio Emilia, 14-15 Ottobre 2003
GiuseppeGiuseppe ScielzoScielzo
Ordine Mauriziano - IRCC, Torino
Contents
IMRT in Italy
- AIFM BEV
- AIRO BEV
- OEV
Ordine Mauriziano - IRCC, Torino
Breaking the ice ...
I’M aRTist in dose painting
Ordine Mauriziano - IRCC, Torino
AIFMjournal
Bollettino AIFM
Ordine Mauriziano - IRCC, Torino
Istituzione del gruppo IMRT-AIFM
Incontro istitutivo del gruppo IMRT-AIFM il giorno Venerdì 17 Gennaio 2003
AIFMIMRT group
Ordine Mauriziano - IRCC, Torino
IMRT AIFM
groupQuality
assurance
Radiobiological modelling and dose-response function
A computational approach on IMRT
Dosimetry
Multimodality Imaging
Bologna, 27th March 2003
Ordine Mauriziano - IRCC, Torino
UOA Radiobiologia clinica Università di FirenzeCasa di cura S. Chiara - Firenze:
Dynamic μMLC ERGOGAFchromic MD55 and Exradin micro-chamber Clnical experiences on IMAT
IEO - Milano
μMLC BrainLAB and 3D-Line dMLC.60 dynamic arc stereotacties and 70 prostatesProblem in leaves speed with BrainLab
Ospedale S. Anna - Como
TPS Varian-EclipseClinac 6EX Millenium 120MLCsliding windowX-Omat V, EDR2, EPID and diodes linear arrayPMMA and anthropomorphic RW3 phantoms
Bologna, 27
th March 2003
Ordine Mauriziano - IRCC, Torino
Istituto Regina Elena – Roma
TPS Helios-CadplanVarian Clinac 2100CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with Films (evaluated with Gamma function)
and ionization chamberIMRT executed on H&N and prostateTests on maximum leaf speed vs predicted position
IRCC di Candiolo e Ospedale Umberto I° - Torino
TPS Varian Helios-CadplanVarian Clinac 600CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with films and ionization chamber21 patientsIMRT in complex cases: the aim is dose escalation and OAR sparing
Bologna, 27
th March 2003
Ordine Mauriziano - IRCC, Torino
Ospedale S.Giovanni Calibita FatebenefratelliIsola Tiberina - Roma
TPS Helios-Cadplan2X 2100CD Varian 80-MLCsliding windowLoSasso protocolpre-treatment QA with Films, MapCheck and ionization chamberFluence verification every 10 sessions
Vicenza
TPS Pinnaclestep & shootpre-treatment QA with Films and Exradin A14SLtests for small fields and small MU (down to 1 MU)Monte Carlo tests
Bologna, 27
th March 2003
Ordine Mauriziano - IRCC, Torino
Firenze-CareggiTPS RenderPlanElekta with 80-MLCstep&shootpre-treatment QA with films and ionization chamber
(home-made software for evaluation)prostate patients
Reggio EmiliaTPS Helios-CadplanVarian Clinac 600CD 80-MLC and
Clinac 2100CD 120-MLC Milleniumsliding windowLoSasso protocolpre-treatment QA with films and ionization chamber80 patientsIMRT for high conformation and fractionated treatment SMART
Bologna, 27
th March 2003
Ordine Mauriziano - IRCC, Torino
ESTRO Meeting 2003Talks and poster @ Geneva
90
116
152
154
238
239
267
292
295
Torino
Vicenza
Milano
Reggio Emilia
DMLC & IMRT verification
Monte Carlo verification...
Monte Carlo verification...
Monte Carlo verification...
Ion chamber for IMRT...
Clinical exp of IMRT...
Clinical exp of IMRT...
IMRT implementation...
IMRT implementation...
Ordine Mauriziano - IRCC, Torino
AIRO IMRT Group
e.g. Quality assurance in IMRT
Ordine Mauriziano - IRCC, Torino
Gruppo AIRO IMRT⊗ Treated disease
⊗ Immobilization devices
⊗ Imaging
⊗ Treatment planning
⊗ Pre-treatment plan verification
⊗ Treatment verification (and frequency)
⊗ Tolerance limits on positioning
⊗ Documentation on immobilization
⊗ Immobilisation devices storage and conservation
⊗ Quality manual
Ordine Mauriziano - IRCC, Torino
IMRT in Italy
Will IMRT guide the exploitation of several relevant good things that already exist in
all the radiotherapy chain ?
Insight view in the clinical practice and a glance into the crystal ball
Great opportunity of starting something new together
Ordine Mauriziano - IRCC, Torino
IMRT present & futurep overall infrastructure PACS+R&V+RIS
p imaging multimodality
p treatment planning & dose calculation
p virtual vs real simulation
p patient positioning and IGRT
p delivery system
p treatment verification
p tumor response and radiobiological model
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Overall infrastructureOverall infrastructure
Record and verify + RIS + Radiology PACSRecord and verify + RIS + Radiology PACS
Integration and verification !Integration and verification !Integration and verification !
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TreatmentTreatment segmentsegment
CLINAC 2100C/D
Vision server
Radiology and N
uclear Medecine PA
CS
VerificationInterface
Treatment workstation
CLINAC 2300C/DVerificationInterface
Treatment workstation
CLINAC 600C/DVerificationInterface
Treatment workstation CADPLAN
9 Varis workstations
RT Simulator
9 Vision workstations
PLATO
WorkstationWorkstation segmentsegment
PINNACLE
Varis server
HospitalHospital LANLAN
HUB
HUB
FOCUS
Infrastructure for IMRTInfrastructure for IMRT
Hospital RIS
Ordine Mauriziano - IRCC, Torino
DICOMtypes
DICOMtypes
DICOM standard for imagesDICOM standard for images
RadiotherapyRadiotherapy
Nuclear Nuclear medecinemedecine
Image Image diagnosticdiagnostic
PACS
Medical Medical PhysicsPhysics
TCTC RMRM γ cameraγ camera
TCTC
PETPET
INTEROPERABILITY & CONNECTIVITYINTEROPERABILITY & CONNECTIVITY
- Computed Radiography - Direct Radiograph
- Computed Tomography- Digital Mammography
- Magnetic Resonance- Ultrasound- Secondary Capture- Nuclear Medicine
DRDR
SimulatorSimulator
Ordine Mauriziano - IRCC, Torino
Soma-VisionSoma-Vision
Cadplan Umberto ICadplan Umberto I PinnaclePinnacle PlatoPlato
XIO-FocusXIO-Focus
DICOM-RT stuctureDICOM-RT stucture DICOM-RT planDICOM-RT plan
Focal IRCCFocal IRCC2 Cadplans IRCC2 Cadplans IRCC
Focal Umberto IFocal Umberto I
ExomioExomioDICOMRT standard for radiotherapyDICOMRT standard for radiotherapy
RTPXRTPXUmberto I e IRCCUmberto I e IRCC
RT DoseRT Beams Treatment Record, Brachy Treatment Record, Treatment summary record
RT Structure setRT Plan
RT Image
DICOM RT
DICOM RT
Ordine Mauriziano - IRCC, Torino
Imaging multimodalityImaging multimodality
• CT electron density
• MRI proton density
fMRI morpho-functional
MRSI metabolism
• PET morpho-functional
CT-PET morpho-functional + anatomical
• Molecular Imaging
• CT electron density
• MRI proton density
fMRI morpho-functional
MRSI metabolism
• PET morpho-functional
CT-PET morpho-functional + anatomical
• Molecular Imaging
Ordine Mauriziano - IRCC, Torino
CT- MRICT- MRI
CT- PETCT- PET
Image registration and fusionImage registration and fusion
The future: Autocontouring?
The future: Autocontouring?
Merging of anatomical-morphological information
Courtesy of Kessler
Ordine Mauriziano - IRCC, Torino
- Standard MRI imaging
- Spectroscopy on VOI
- Standard MRI imaging
- Spectroscopy on VOI
Morphofunctional imaging: MRSIMorphofunctional imaging: MRSI
Brain Prostate
- Search of metaboilte peaks:
MyoinositolCholine
CreatineN-acetilaspartate
LipidsLactateCitrate
- 3D Maps of metabolites
concentration - Quantitation
Ordine Mauriziano - IRCC, Torino
Morphofunctional imaging: PETMorphofunctional imaging: PET
Tumor staging
GTV, PTV delineation
Tumor response
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Biological targetBiological target
Ordine Mauriziano - IRCC, Torino
Treatment planning & dose calculationTreatment planning & dose calculation
Inverse planning techniqueDose calculation algorithmsInverse planning techniqueInverse planning techniqueDose calculation algorithmsDose calculation algorithms
Ordine Mauriziano - IRCC, Torino
Inverse PlanningInverse Planning• Cost function
• Search technique
• Dose calculation
Optimisation with:
• geometrical uncertainties
• beam angle
• EUD
• TCP/NTCP
Ordine Mauriziano - IRCC, Torino
Geant4 Parallelised Monte Carlo Simulation on Beowulf Cluster of IMRT treatmnent
Grant AIRC2001-02
Geant4 Parallelised Monte Carlo Simulation on Beowulf Cluster of IMRT treatmnent
Grant AIRC2001-02
Dose calculation for IMRT
Dose calculation for IMRT
Pencil beam Pencil beam Superposition/convolutionSuperposition/convolutionMonte CarloMonte Carlo
High dose and density gradient
Ordine Mauriziano - IRCC, Torino
SimulationSimulation
Simulation: real vs virtual Simulation: real vs virtual Simulation: real vs virtual
Ordine Mauriziano - IRCC, Torino
Target and OAR are not clearly seen on projection
Target and OAR are not clearly seen on projection
3D visualisation and rendering of target and OAR
3D visualisation and rendering of target and OAR
Low cost (no simulator needed)Low cost (no simulator needed)Correct set-up between CT and
treatment Correct set-up between CT and
treatment
Virtual vs real Virtual vs real
Fast acquisitionFast acquisition
Integration with imaging, TPS and machine
Integration with imaging, TPS and machine
Automatic isocentre positioning with mobile laser
Automatic isocentre positioning with mobile laser
2D visualization2D visualization
Ordine Mauriziano - IRCC, Torino
Patient positioningPatient positioning
Immobilization system Verification Immobilization system Immobilization system Verification Verification
Ordine Mauriziano - IRCC, Torino
Termoplastic mask
⇒
Stereotactic system
Immobilization systemImmobilization system
Van Herk,,1998
Courtesy of Agosti
Ordine Mauriziano - IRCC, Torino
Courtesy of Yan
Image Guided RadiotherapyImage Guided Radiotherapy
4D treatment planning
Ordine Mauriziano - IRCC, Torino
Real time verification of- Isocenter- Dose distribution
Real time verification of- Isocenter- Dose distribution
Treatment verificationTreatment verification
Dosimetry
- matrix of ion chamber
- amorphous Silicon
Ordine Mauriziano - IRCC, Torino
New delivery systemNew delivery system
On line organ motion monitoring with infra-red tracking system and X-ray stereo-imagingOn line organ motion monitoring with infra-red tracking system and X-ray stereo-imaging
CyberknifeCyberknifeCyberknife
Ordine Mauriziano - IRCC, Torino Courtesy of Francescon
Ordine Mauriziano - IRCC, Torino
New delivery systemNew delivery system
On line simulation contouring and treatment with CT like MV source On line simulation contouring and treatment with CT like MV source
TomotherapyTomotherapyTomotherapy
Ordine Mauriziano - IRCC, Torino
Tomotherapy unitTomotherapy unit
Courtesy of Tomotherapy IncCourtesy of Webb
Ordine Mauriziano - IRCC, Torino
New delivery systemNew delivery system
Protontherapy and hadrontherapy in Italy???? Protontherapy and hadrontherapy in Italy????
IMPTIMPTIMPT
Courtesy of Lomax
Ordine Mauriziano - IRCC, Torino
DVH and dose distributionDVH and dose distributionThanks to C
ozzi Fogliata
IMRT protons3D-CRT
0%
20%
40%
60%
80%
100%
120%
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Midollo
Parotide sinParotide des
PTVIPTVIII
0
20
40
60
80
100
120
PTVIII
PTVI
midollo
Ordine Mauriziano - IRCC, Torino
Tumor response and radiobiological model
Tumor response and radiobiological model
Immobilization system Verification Immobilization system Immobilization system Verification Verification
Ordine Mauriziano - IRCC, Torino
Tumor response and radiobiological modelTumor response and radiobiological model
Dose distribution in the target less
homogeneous than in 3DCRT
• greater number of MU: greater leakage
• dose paint: hypoxic regions?
• α/β ratio: prostate case…
• integral dose unchanged
Some radiobiological issue in IMRT
polmones=0.0061
vescicas=1.3
esofagos=3.4
KAB ---- LBK
polmone
esofago
vescica
Courtesy of IFO-Roma
Ordine Mauriziano - IRCC, Torino
Thanks Thanks Thanks
And the future?
All is possible: just do it.