IMRT/VMAT with MC Dose
Calculation
Frank Lohr, M.D.
University Medical Center Mannheim
Germany
Disclosure
Cost of Travel provided for by Elekta
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Most important indications and treatment philosophy
1. Head and Neck Cancer
CNS
Paranasal Sinus Tumors / Integrated Boost
(Better Tumor coverage and shortening of
overall treatment time)
NPC and other ENT Tumors
(Parotid sparing when possible, better tumor
coverage for NPC)
2. Prostate / Integrated boost
(Potentially hypofractionation)
3. Gastric cancer
(Better kidney sparing while treating the whole of the target)
4. Breast Cancer
5. Lung Cancer
6. Metastases
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„Unexpectedly, acute
fatigue was greater in
patients treated with IMRT,
which could be due to the
greater radiation dose to
non-tumour tissues. In an
unplanned dosimetry
review in a subset of
patients, mean radiation
doses to the posterior
fossa were 20–30 Gy in the
patients treated with IMRT
compared with about 6 Gy
in patients treated with
conventional RT“
Nutting et al., Lancet Oncol, 2011
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Parotid Tolerance -> The (almost) definitive data….
Deasy/Eisbruch, IJROBP, 2010
Dijkema/Eisbruch, IJROBP, 2010
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10J post full neck IMRT
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Paranasal Sinus
Integrated Boost
No
Dry Eye
Syndrom
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Tumor Localizations
3. Gastric Cancer as an example of a Large Abdominal Target
3DCRT IMRT
Right Kidney (Gy) Left Kidney (Gy)
Cranial Middle Caudal Cranial Middle Caudal
Median Mean D30 D60 Median Mean D30 D60
part part part part part part
3DCRT-1 2.52 3.18 3.3 2.4 5 <5 <5 41.07 36.9 46.3 38.4 47.8 45.3 25.2
3DCRT-2 3.2 7.76 8.1 2.7 22.5 4.5 <4.5 25.8 22.95 27 18 45 42.7 36
IMRT-1 1.49 1.61 1.77 1.39 11 5 0 20.25 22.18 26.68 18.15 29 26 9
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IMRT-2 14.77 16.12 17.4 13.8 13 8 4 23.84 23.28 27.7 21.2 26.8 18.5 13.5
OS DFS
Boda-Heggemann et al., IJROBP, 2009
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T2w: (A) IMRT vs. (B) 3D
A B
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Tumor Localizations
4. Breast Cancer
Optimization of Tangent Irradiation
Abo Madyan et al., Strahlentherapie, 2007
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Breast IMRT reduces Maximum dose to the heart at the expense of
higher low dose exposure and a higher dose to the contralateral breast
El Haddad/Lohr et al., IJROBP, 2008
Distribution of Coronary Artery Stenosis After Radiation for
Breast Cancer
Nilsson, JCO, 2012
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Tumor Localizations
5. Lung Cancer
Image Guided, PET-assisted Radiotherapy of Lung Cancer
Target Volume Reduction and RT-Optimization for critical Tumor-to-Lung Ratio
1. CTV-Definition/Minimimization
based on functional Imaging (PET-CT)
Suboptimal Positioning
Optimal Positioning
3. Image Guided Radiotherapy Treatment
2. Treatment Planning as IMRT based on with Cone-Beam-CT at Linac
Monte-Carlo Dose calculation
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Fleckenstein et al., submitted
Measurement setup
IBA Matrixx Evolution
IBA Multicube
CIRS dynamic platform
model 008PL (accuracy
0.05mm)
VMAT plan generated in
Monaco [Link]
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Fleckenstein et al., submitted
A=10mm, T=3.6s, cos4-motion trajectory
static case with motion difference map
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Monaco® 201:
Leveraging the experience of more than
1000 Monaco with VMAT patients
Frank Lohr, Jens Fleckenstein
University Medicine Mannheim, Germany
Oct. 1st, 2011
20th Elekta User Meeting
Miami, USA
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ELEKTA MOSAIQ Vers. 2.4
Philips Brilliance Big Bore LINAC 1 Elekta Precise
CT-Simulation X 6,18; e, MLC,EPID
Philips Eleva LINAC 2 Siemens Mevatron
PCR System X 6,23; e, MLC, EPID
Elekta ABAS Replacement 2011/12
Atlas based autosegmentation - x 6,10,18
-160 leaf MLC
- FFF- machine
5 x Elekta Monaco 3.2 LINAC 3 Elekta Synergy
Monte-Carlo Systems X 6; e, MLC,EPID,cone beam
Integrity
LINAC 4 Elekta Synergy
X 6; e, MLC,EPID, cone beam,
Integrity
6 x Nucletron
MOSAIQ
Masterplan vers. 4.0
90 clients Intraaoperative unit
Zeiss Intrabeam, 50 KV
Connection to
satellite 2 in a
distance of 30 km
Connectio to satellite 2
Start Nov.2011
Distance 1 km LINAC 5 Elekta Synergy
X 6; e, MLC, EPID
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Our Patient Mix for VMAT
treatment plans by entities/modalities
560 samples
Oct 2010-May 2011
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QA for VMAT Boggula et al, submitted
• So far
• Extended Linac QA according DIN 6847-5
• Full patient plan verification using EDR2/Gafchromic film and ion chambers
• In vivo dosimetry during patient delivery for prostate cancer
• Recent additions: IBA Multicube
• IBA MatriXX 2D-arry detector for patient plan verification
• MatriXX Evolution with gantry angle sensor
and multicube phantom
(Comparison of measurement to TPS)
IBA Compass
• MatriXX Evolution with gantry holder
and Compass software (independent TPS using
measured fluences)
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IBA transmision detector
VMAT specific linac QA
test 1: gantry accuracy
360°arc – open field (24 cm x 24 cm)
test 2: field sizes, MLC dynamic
„slide and pause“ MLC motion (2 cm x 20 cm)
Matrixx Iview
J. L. BEDFORD and A. WARRINGTON “Commissioning of
Volumetric Modulated Arc
NameTherapy
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I Datum Int. J. Radiation
Oncology Biol. Phys., Vol. 73, No. 2, pp. 537–545, 2009.
off-axis-target test
test 3: MLC and Gantry
synchronization
modulated VMAT arc, which delivers
dose to a PTV 8 cm from isocenter
(16 cm x 1 cm field)
interrupt
terminate
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irregular MLC shaped field
measurement setup
film measurement
Gamma map (3%,3mm)
σMonaco = 0.5 %, σGeant4 = 1.3 % on a 2 mm dose grid
γ(3 %, 3 mm) in the ROI10 :
•97.3 % for film measurement against Monaco
•99.0 % for film measurement against Geant4 and
•99.4 % Monaco against Geant4
•
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irregular MLC shaped field
profiles with profiles with
initial Monaco ® head model adjusted Monaco ® head model
Fleckenstein et al., submitted
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Fleckenstein et al., submitted
Dose to water – dose to medium conversion
film measurement setup CT-slice
Monaco dose slice global gamma dm-dw corrected
(3%,3mm) gamma (3%,3mm)
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Fleckenstein et al., submitted
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Monaco ® vs. Geant4
patient with metallic implants
mean deviation of the organs at risk:
(0.7± 0.3) % of D50(PTV)
σMonaco= 0.4 %, σGeant4= 1.6 %
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Lung Tumor boost
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Breast will in a bit be exclusively tangential IMRT
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Cutaneous Melanoma Metastases
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VMAT for Reirradiation of
Paraspinal Tumors
Stieler et al. submitted
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Gastric Cancer
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Hodgkin‘s Disease
Koeck et al., IJROBP, 2012
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Anal Cancer
640 MU
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BOT 8 min
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VMAT
562 MU/1.5 Gy
T~ 3 min 30 sec
In June 2010 (already tested on
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Step-and-Shoot IMRT
695 MU/1.5 Gy
92 Segments
T= 13 min
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Static Gantry IMRT VMAT
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VMAT vs. IMRT treatment plan comparison
convex PTV shapes tend to yield similar treatment quality in
less time
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VMAT Customer Perspective
and
Schmid et al.,
Radiother Oncol, 2012
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Divide Treatment times by >2 for
- Agility MLC (aka „The Onesixty“)
- plus Monaco 3.2
(Now on sale at an Elekta Dealer near you)
Well, rather FOR sale, certainly not ON sale……..
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Problems
2. Secondary Tumors
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Secondary Tumors
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Secondary Tumors
Secondary Sarcoma (Sarcomas arise in
High Dose Volume
-> no large difference between
conventional 3D-RT and IMRT)
Secondary Carcinoma (Carcinomas arise in
Low Dose Volume, this is
larger for IMRT than for
conventional 3D-RT)
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Secondary Carcinoma
is not a relevant problem for old patients
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Secondary
Carcinoma
is not a relevant
problem when
patients with a bad
prognosis (such as it
is the case with
advanced gastric
cancer) are treated.
Achieving cure is the
problem for these
patients.
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Secondary Tumors: H&N
Risk is not different from 3D if the whole diameter is irradiated
Head and Neck:
Irradiation of (more or less) the
whole neck circumference with
therapeutic doses (volume very
similar to conventional 3D
[paradigms changing slowly])
->similar risk for secondary
tumors for IMRT and 3D in the
Neck area, probably slightly
elevated risk outside neck due
to elevated MU, increased
scatter. High risk for secondary,
non RT-induced cancer, though
(Lung!!)
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1 Gy (blue), 5 Gy (green), 45 Gy (yellow) and 70 Gy (red)
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Low Doses are
evil…….are they???
Slanina et al., Strahlentherapie, 1999
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Secondary Tumors
Hall, IJROBP, 2006
Pediatric Oncology is a problem…but not a disastrous one
The St. Jude Data….Conventional RT Techniques!!!!!
Hijiya, JAMA, 2007
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But:
Threshold energy for
neutron generation is 6-8
MV,
thus relevant only at >10MV
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Increase of the risk for secondary tumors of appr. 1% for
conventional RT by 0.5% because of larger low-dose-
volume and by another 0.25% by scatter/leakage
Risk of 2ndary tumors after IMRT < 1.75% (vs. 1%
bei 3D-CRT)
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Mediastinal Tumors: Hodgkin‘s Disease
Elevated median but reduced mean breast dose as a result of improved heart
protection -> Consequences???
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Problems with Modelling
“The mean estimated ERR for breast, lung and thyroid were significantly
(p < 0.01) lower with INRT than with IFRT planning, regardless of the
radiation technique delivery used, assuming a linear dose-risk
relationship. An ERR increase was however observed with the non-linear
model. With the latter, mean ERR were significantly (p < 0.01) increased
with IMRT or RA when compared to 3DCRT planning for the breast, lung
and thyroid using an IFRT paradigm. After INRT planning, IMRT or RA
increased the risk of RIC for lung and thyroid only. “
Weber et al., IJROBP, 2011
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Breast:
Increase of mean and median
contralateral breast dose very
moderate (from 1.5 to 2.5 Gy)
while improved heart protection
can be achieved
(Example:
23 Segments - 7 Beams - 362
MUs)
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Where
the
real
danger
lurks……
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Where the real
danger lurks……
Cancer, 2012
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Courtesy M. Alber/F. Stieler
A Sneak Preview at MONACO 3.2
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