ws07 vmat in thoracic malignancies

8/7/2019 WS07 VMAT in Thoracic Malignancies

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The Royal Marsden

VMAT in thoracic malignancies

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Dr. Maria A. HawkinsConsultant Clinical Oncology

The Royal Marsden Hospital NHS FT


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The Royal Marsden2

Disclosure

received research funding from Elekta


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VMAT

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New technology competition

Cyberknife - good marketing, intracranial sites

Tomotherapy- all in one solution (IMRT only)

Protons-costly, not yet proven to be superior in certaintumour sites, not yet widely available

VMAT- linac based technology, more precise treatment,short delivery time, potentially more accessible


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Further evolution of IMRT

one/more gantry arcs

Continuously varying

VMAT

Beam aperture Gantry speed

Dose rate


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The Royal Marsden6Planning techniques-VMAT


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VMAT Benefits

Faster treatment times

Improved target dose conformality

Beam modulation

Reduced dose to OAR

3D volumetric imaging necessary for deliveryaccuracy


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Why speed matters?

Patient comfort

Intrafraction organ motion/Opportunity to use gating

o og ca e ec s- mprove c n ca ou comes

Patient throughput increased

Planning time - possibly faster once solution found


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Improved conformality/reduced OAR dose

Reduce toxicity further

Dose escalation

Hypofractionation

Re-treatment to radical doses


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3D volumetric imaging needed for VMAT

Improves accuracy

set-up margin reduction

Soft tissue visualization

Opportunity to adapt treatment if tumour/patient changesvolume/shape


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Tumour sites VMAT opportunities

Replace IMRT prostate/H+N/Gynae

Replace 3DCRT: GI-upper_lower/lung

SBRT: lung/liver/paraspinal

Palliative: vertebral body/H+N re-treatment

Other sarcoma, CNS


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VMAT lung cancer

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3D conformal vs IMRT vs VMAT

Planning study

5CT datasets of patients treated with radical RT fornon-small cell lung cancer

9 p ans IMRT 3, 5, 7, 9 fields coplanar

IMRT 3, 5, 7, 9 fields non-coplanar

VMAT

Brock ESTRO 2008


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3D conformal Radiotherapy

Brock ESTRO 2008


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IMRT plans VMAT

VMAT

5 F coplanar

7 F coplanar

Brock ESTRO 2008


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IMRT plans VMATFields arrangement

Brock ESTRO 2008


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PTV 95% isodose coverage

Brock ESTRO 2008


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Lung V20 comparison

Brock ESTRO 2008


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Inoperable stage III Non-small Cell Lung Cancer

Conformal plan

Bedford Acta Oncol 2008


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Inoperable stage III Non-small Cell Lung Cancer

VMAT plan

Bedford Acta Oncol 2008


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1st patient treatedCombined DVH

GTV

PTV

Lungs

Spinal cord

oesophagusheart

VMAT 3DCRT Bedford Acta Oncol 2008


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1st patient treated

Comparison of 3DCRT and VMAT

Parameter 3DCRT VMAT

PTV min 41Gy 43Gy

V20 35% 32%

Treatment time/# 180secs 90secs


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VMAT lung cancer

VMAT offers same degree of PTV coverage

Lung V20 similar

VMAT is preferable because of significant shortertimes


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VMAT oesophagus

cancer

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Oesophagus

Planning study 10 patients

Gastro-oesophageal junction

54Gy/30# Compared with 3D

Spare heart, liver, cord

Better conformity index

Hawkins BJR 2011


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Sagital plan comparison

Purple=PTVHawkins BJR 2011


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Fig. 1a


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Continuous=clinical

Dashed=VMAT


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40%

50%

60%

70%

at35Gy

Fig. 3

Heart volume receiving 35Gy

0%

10%

20%

30%

1 2 3 4 5 6 7 8 9 10

patient

%Volum

e

Clinical plan VMAT planHawkins BJR 2011


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OAR

Clinical plan VMAT p

Lungs V20 (%) 15%6% 15%5% 0.87

Mean lung dose (Gy) 8.22 9.72.7 0.02

Heart V35 (%) 44%14% 22%4% 0.01

Cord max (Gy) 35.81 29.55 0.02

Hawkins BJR 2011


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VMAT Oesophageal cancer

VMAT offers same degree of PTV coverage

Significant reduction of heart dose

VMAT is preferable because of significant shortertimes


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VMAT clinical data

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The Royal Marsden data thorax patients

34 patients treated between July 2008-June 2010

Age: mean 67 years (range: 43-89) Sex: M/F=17/8

Lung ca=28, dose 50-64Gy in 2Gy/#

ABC used in 11 lung patients 6 lung cancer SBRT part of study (not reported here)

oesophagus ca=6 with concurrent capecitabine 54Gyin 1.8Gy/#

Ahmed Hawkins 2011


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Lung and oesophagus DVH parameters

ORGAN VOLUME MEAN (RANGE)

Lung V5Gy

53.3 (17-92) %

(all patients) V10Gy 38.8 (8-76) %

V20Gy 18.1 (5-53) %

30Gy . -

V35Gy 7.6 (1-21) %

MLD 11.1 (3-19) Gy

Oesophagus V35Gy 22.3 (0-77) %

(lung patients only) V50Gy 13.5 (0-57) %

V60Gy 7.1 (0-49) %

Ahmed Hawkins 2011

h l d


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Acute toxicity (1-90days) Grade 1n=28

Toxicity grade Gr1 Gr2 Gr3

Dysphagia* 10% 33% -

Lethargy 8% 32% 1

Chest pain* - 3

Pneumonitis 29% 7% 3%

Pleural effusion 3 - -

Other Platelets 3.5%

Skin7%

Nausea 7%

Dyspnoea

PE

Pneumonia

*lung patients only Ahmed Hawkins 2011

Th R l M d6


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Acute toxicity (1-90days)

RT stopped early 4 cases

36Gy/50Gy platelets dropping 52Gy/64Gy Dyspnoea gr3

10Gy/64Gy PE

50Gy/64Gy brain metastases

All toxicities resolved at 3 months

Ahmed Hawkins 2011

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Localised pneumonitis 60Gy/8# at 3 mo post RT

Diagnostic CTPlanning and Dg CT fusion

Pink =PTV

Red=100%

Yellow=95%

Light green=70%

Brown=50%

Dark green=5%

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Conclusion

VMAT well tolerated

Pneumonitis rates were low Grade 2


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VMAT studies

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y

VISuAL Study:VMAT Image-guided Stereotactic

Arc therapy for small volumeLun tumours

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PI: Prof. M. Brada

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VISuAL Study

To assess the feasibility of delivery of

hypofractionated RT for early-stage NSCLC 60Gy/8#/3 weeks

using ABC / CBCT / VMAT

To assess associated toxicity andoutcomes

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First patient: VMAT plan

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First patient: CBCT & on line match


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First patient: CBCT & on-line matchPre match

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VMAT clinical implementation

Identify groups that benefit

Need to develop studies to confirm dose modellingpredictions

Keep the plan objectives and goals realistic!

Planning +verification ---more time

Faster delivery ---more patients

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Acknowledgements

Prof. Mike Brada

Helen McNairJuliet Brock

Judith Christian

James BedfordJim WarringtonFiona McDonaldMerina Ahmed

William Beaumont Hospital

Ellen DonovanPhil Evans

RMH Physics

RMH radiographers

RMH Imaging

The Royal Marsden


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Thank you

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ws07 vmat in thoracic malignancies

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