1. EMEA 2009 Tomotherapy User Meeting 4D TOMOTHERAPY : PRELIMINARY DOSIMETRIC ANALYSIS OF THE EFFECTS OF THE TARGET MOTION G.Guidi 1 , M.Amadori 2 , E.Cenacchi 1 , L.Morini 1 , C.Danielli 1 , F.Bertoni 2 1 Medical Physics Dpt. 2 U.O. Radiation Oncology Azienda Ospedaliero - Universitaria di Modena - Policlinico “… under the “Ghirlandina” Tower…. … ..new opportunities and ideas are growing … … and many people are working on it”

3. LET’S START FROM WHO HAS MORE EXPERIENCES THAN US

4. RADIATION ONCOLOGY WORKFLOW ANALYSIS Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population

5. 4D WORKFLOW ANALYSIS (4D TOOLS AND ISSUES) Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Gamma Index? 4D Dose Point? 4D Edge Profile? Accuracy? 4D Inverse Planning (Same results?) Which Plan or Phases? Which Phases to be consider? Trigger Tomotherapy is possible? 4D-MVCT? Tracking the delivery 4D Adaptive RT Reconstruction

6. 4D WORKFLOW ANALYSIS - IMAGING & CONTOURING Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations

7. 4DCT AND GATING/TRACKING DEVICES (TOSHIBA + VISION RT) Advantages: 4DCT Exams (10 CT Dataset – 0-100% Breathing Phases): Very Fast (few minutes) – Retrospective Mode Range Slice thickness for our RT: 0.5 - 3 mm (5mm used for Cranio Spinal Irradiation and TBI) VisionRT detect capability: 1-2mm of the couch movement (VisionRT can appreciate the ramp up of the couch during the CT scan) Issues: 4DCT Images Reconstruction (>1000 Images – 10 CT Datasets – 5/6 Hours of reconstruction) Thickness 0.5mm could be useful for Radiosurgery but dose issues and the Tomotherapy image resample (256x256 ) could create problems Troubles and investigation: Mismatch image reconstruction due to the couch ramp-up and the breathing signal (Sinogramma Editing in develop by Toshiba) Limited Trigger Time of 10 cycles/min not applicable (No idea why ????) Work on Phases 20-60% (5 CT Datasets) - 2-3mm Slice Thickness Contour all CTVs and OARs using TPS (Not Applicable). During routine is contouring Min exhale and Max inhale phases, but is no equal to contour the CTVs for each phases Trick Necessary

8. PINNACLE 4D RESEARCH CONSOLE Contouring Objectives: Define contours that include all the organ and tumor movements due to the cycles Issues: Contouring each phases is very long time consuming using standard TPS Advantages using Pinnacle 4D Console: Contouring the CTVs of the Multiple Phases (20-60%) and propagate ROI and OARs to all others 4DCT exams Use the Model Based Segmentation to speed up the contouring time Create an average MIP exams to accelerate the evaluation of the volumes Create an ITV as integration of all the CTVs contoured in each phases Beta Test Console: Courtesy of TA Tecnologie Avanzate CT Movement Artifact (Lung or Liver)

9. FOCAL 4D RESEARCH CONSOLE Contouring Objectives: Define contours that include all the organ and tumor movements due to the cycles Issues: Contouring each phases is very long time consuming using standard TPS Advantages using Focal 4D Console: Contouring the CTVs of the Multiple Phases (20-60%) using MIP Cine Contouring on axial, coronal and sagittal view Propagate ROI and OARs to all others 4DCT exams Create an ITV as integration of all the CTVs contoured in each phases Beta Test Console: Courtesy of TEMA Sinergie

10. 4D WORKFLOW ANALYSIS – PLANNING & DOSE COMPUTATION Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D Inverse Planning (Same results?)

13. 4D MARGIN EVALUATION (4 PLANS : TARGET=PTV) PTV=CTV PTV=ITV PTV=CTV+0.5cm PTV=CTV+ 1cm Suspected CTV Voxel Issue correlated to the dose grid or to the image resample : Under investigation CTV ITV CTV ITV CTV ITV CTV ITV

14. 4D DOSE RECONSTRUCTION 4D DOSE RECONSTRUCTION OF THE RESPIRATORY PHASES (Possible!!! But I will be crazy, if it will be a clinical routine (3 days of work)) Dose Matrix (Phase 20%) + Dose Matrix (Phase 30%) + Dose Matrix (Phase 40%) + Dose Matrix (Phase 50%) + Dose Matrix (Phase 60%) + ------------------------------------ 4D Dose Reconstruction The breathing sinogramma will define the time (BIN) for each Dose Matrix

15. 4D QA Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Inverse Planning (Same results?)

16. LET’S GO TO THE QA AND ANALYZE THE REAL DOSES DELIVERED (DQA) THEORY AND PRACTICE COULD BE DIFFERENT Preliminary dosimetric issue of the Patient DQA using QUASAR Phantom Respiratory phases 15 cycles/min Active Target Simulation : 0.5 cm movement (Cranio – Caudal) during Tomo delivery The dynamic phantom has a dedicated Gaf-Chromic and Ion chamber insert Dosimetric differences appraisal using Gaf-Chromic Film X Coordinate: Edge of the CTV near the Gantry Y Coordinate: CTV Coronal Profile Dose measured and calculated are different and shifted, especially near the tumor edges Gamma Index 3%@3mm can help me ? Calculated : 2.25 Gy Measured : 1.75 Gy

20. TRY TO SIMPLIFY THE PROBLEMS .... VERY SIMILAR RESULTS Preliminary results using a dynamic Phantom (Quasar) Respiratory phases 15 cycles /min Cranial Caudal direction Analysis (4D Phantom can’t permit to analyze the X,Y,Z coordinate at the same time) Target Movement: 1 cm Morphing of the structures (4D Issue and Investigation) Dosimetric impact of the structure morphing due to respiratory motion Dose Shift 1cm Cranial under dosage and caudal over-dosage should be considered Dosimetric results on Gaf-Chromic: shift of  1cm (Cranial Caudal direction) MODERATE DOSE DIFFERENCES BUT GAMMA INDEX AND DOSE ACCURACY NOT ACCEPTABLE FOR A PATIENT TREATMENT Gamma Index due to respiratory motion

21. 4D ADAPTIVE RADIATION THERAPY Multi-modality Imaging Immobilization Verify and Monitor Delivery Deliver Treatment Pre-Verify Dose/Position Simulation Forward Planning Treatment setup Dose computation Inverse Planning Define Objectives Optimize Plan Analysis Dose Accuracy Target and Structure Definition Image Patient Adaptive Analysis Delivery System QA Export to Delivery System Pretreatment CT Guidance Modify Plan/Patient Position Planning 4D Components Delivery Export for Population 4D Images (>1000) 4D Tools & Issues 4D Contouring Propagate ROIs? MIP Contouring? 4D OARs Volume Deformations 4D Planning (0-100% Phases)? 4D Dose Computation – Phases? 4D Analysis (Multiple Plan) 4D QA (Dynamic Phantom) 4D Gamma Index? 4D Dose Point? 4D Edge Profile? Accuracy? 4D Inverse Planning (Same results?) Which Plan or Phases? Which Phases to be consider? Trigger Tomotherapy is possible? 4D-MVCT? Tracking the delivery 4D Adaptive RT Reconstruction NO ANSWER AT THE MOMENT... ... BUT FEW IDEAS TO USE MVCT