ClinicalExperiencewithNonInvasive ... · SEAAPMScien+fic&Mee+ng& May&2,&2014& Chaanooga,TN&!...
Transcript of ClinicalExperiencewithNonInvasive ... · SEAAPMScien+fic&Mee+ng& May&2,&2014& Chaanooga,TN&!...
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SEAAPM Scien+fic Mee+ng May 2, 2014
Cha7anooga, TN
Ahmad Al-‐Basheer, PhD, MPH Chief Medical Physicist
Department of Radia<on Oncology Georgia Regents University
Clinical Experience with Non-‐Invasive Image-‐guided Breast Brachytherapy
(NIBB)
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Disclosures
I have no conflicts of interest
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Outline
• Background • NIBB Clinical Implementa<on • NIBB Vs. Electron boost • NIBB for APBI • Physics • Conclusions
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3D conformal Breast Irradia<on • Performed on a standard
linear accelerator; non-‐invasive.
• Requires <me for delinea<on and planning
• Concern for dose to heart, lung, and contra-‐lateral breast
• More issues with breathing mo<on and setup uncertain<es.
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Minimal overlap of the two volumes was noted in the plans based on this pa+ent, resul+ng in significant under dosing of the tumor bed and unnecessary irradia+on of the breast +ssue.
Benda et al., 2002
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Breast Brachytherapy Inters++al Mul+-‐catheter Brachytherapy: Pros:
Flexibility in conforming to complex geometry Long-‐term follow up data
Limita+ons: Invasive Risk of catheter related infec+on Not acceptable to many women
Intra-‐Cavitary Balloon Brachytherapy (MammoSite) Pros:
Simplified single entry technique Simplified dosimetric geometry
Limita+on: Seroma cavity can mimic balloon shape
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Concerns with current Breast Irradia<on Techniques
• Cosme<c outcomes. • Skin sparing. • Invasive procedures. • Post treatment complica<ons (infec<on).
• Tumor targe<ng (are we missing the Target?).
• Radia<on doses to the heart and lungs.
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NIBB Unit
X-ray Tube
Imaging Cassette
Compression Plates
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Process is repeated in an orthogonal axis
Breast Compression
kV imaging in immobilized
posi<on
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Two Orthogonal Treatment Axes
Medial–Lateral (ML)
Cranial–Caudal (CC)
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Electrons vs NIBB Electron Boost Targeting NIBB Targeting
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NIBB Vs Electron Boost Dosimetry
Conven<onal Electron Boost – 90% isodose line grazes the lung & 50% isodose line penetrates deeply into the chest cavity
AccuBoost – The 10% isodose line barely penetrates the chest cavity
Shioshansi et al. IJROBP 2011
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Position Adjustment The positioning accessories for the pair of applicators are set to the alphanumeric coordinates of the isodose center.
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Applicators • 1st Genera<on Round Applicators • D-‐Applicators • 2nd Genera<on Round Applicators (skin-‐dose op<mized
SDO) and (dose-‐rate op<mized DRO) applicators
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D-‐Applicator The D-‐Shaped Applicators avoid interference with the chest wall for deep seated lumpectomies.
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Schema<c Comparison of 1st and 2nd Genera<on Applicators
Second genera<on applicators: different height (25mm, 19 mm), coned field
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2nd Genera<on Round Applicators Gafchromic film Depth Dose profile
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0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.0 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4 5.7 6.0 6.3 6.6 6.9 7.2 7.5 7.8 8.1 8.4 8.7 9.0 9.3 9.6 9.9
Skin Dose (Ra+
o of prescrip
+on do
se)
Separa+on (cm)
Average Skin Dose by Applicator Type
6 cm Round
6 cm SDO
6 cm DRO
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Toxicity for NIBB Vs EB in WBI
Leonard et al., 2013
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0
25
50
75
100
1 2
Percen
t (%)
Boost Method
Acute Toxicity
Grade 3 Grade 2 Grade 1 Grade 0
NIBB
EB
Acute Toxicity (RTOG Grade)
0
25
50
75
100
1 2
Percen
t (%)
Boost Method
Late Skin/Subcutaneous Toxicity
Grade 3 Grade 2 Grade 1 Grade 0
NIBB
EB
Late Toxicity (RTOG Grade)
Leonard et al., 2013
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Par<al Breast Irradia<on
• Convenience – Treatment in 1 week or less rather then 4-‐7 weeks.
• Sparing of non-‐target <ssues – Decreased acute skin reac<on – Poten<al for decreased late effects and improved cosme<c outcomes
– Sparing of lung and heart
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Dosimetric Comparison of APBI using 3D-‐CRT and NIBB
Sioshansi et al. IJROBP 2011
Three - Dimensional Dose Modeling of the AccuBoost Mammography - Based Image - Guided Non - Invasive Breast Brachytherapy System for Partial Breast Irradiation
S.Sioshansi, 1,2 J. R. Hiatt, 2 M. J. Rivard, 1 J. T. Hepel, 1,2 G. A. Cardarelli, 2 S. O'Leary, 1 D. E. Wazer 1,2 1 Department of Radiation Oncology, Tufts Medical Center, Tufts Un iversity School of Medicine, Boston, MA
2 Department of Radiation Oncology, Rhode Island Hospital, Brown U niversity School of Medicine, Providence, RI
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Results: PTV Dose Comparison
No difference in target Coverage
Sioshansi et al. IJROBP 2011
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Results: PTV Dose Comparison
NIBB more heterogeneous like other brachytherapy
techniques Sioshansi et al. IJROBP 2011
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Results: PTV Dose Comparison
Target volume decrease à 1/3!!
Sioshansi et al. IJROBP 2011
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Normal Tissue Dmax Comparison
Sioshansi et al. IJROBP 2011
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Normal Tissue Dmax Comparison
APBI CW Max
(cGy) Lung Max
(cGy) Skin Max
(cGy)
Median AccuBoost [p25-p75]
32.4 [27.4, 88.4]
18.7 [17.6, 25.4]
94.8 [76.5, 101]
Median 3D-CRT [p-25-p75]
99.9 [95.1, 100.5]
91.9 [88.4, 98]
104 [103.5, 106]
p-value 0.01 0.02 0.04
x3 x1.1 x4.5
Sioshansi et al. IJROBP 2011
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Non-‐invasive Image-‐guided Breast Brachytherapy
• Novel technique for par<al breast irradia<on – Non-‐invasive – Precision Targe<ng – Breast immobiliza<on
• No need for large PTV margins
– Image-‐guidance – Collimated photon emissions using Tungsten alloy applicators
– U<lizes HDR 192Ir source
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Physics
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Verifica<on Studies Dose Delivery
• QA phantom based verifica<on of dose delivered to simulated breast center
• Methods – Ioniza<on Chamber – Gafchromic Film
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Round applicator film measurements
QA setup Gaph chromic film isodose distribu+on using two 6 cm diameter Round applicator
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Verifica<on Studies Source Posi<on Verifica<on
• Gafchromic film • Apply to film, tape into circle
• Run source to 500 mm beyond end of current transfer tube, verify no obstruc<on
• Expose film with all required dwell posi<ons
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Con<nuing QA Key Considera<ons • Plate Separa<on (compression thickness) • Applicator Catheters (inspec<on and replacement)
• Transfer Tubes • Alignment Verifica<on • Integra<on into overall x-‐ray QA • Image Quality Verifica<on
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Second Check Op<ons
• 2nd review all primary inputs • Second Check tables • Create independent analy<cal fit to measured data ( dose-‐depth curves)
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Dose delivery nomogram
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Second Check Tables
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SCD Tables/Plots • General Guidance for Applicator Selec<on • Max Skin dose for a given applicator type and breast separa<on
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Limita<ons of NIBB
• No Interlock system (no record and verify) • Online treatment planning and applicators selec<on
• Not an op<on for all pa<ents • Can be exhaus<ng for some pa<ents • Requires long Physics and Physicians <me
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Conclusions – NIBB represents an alternative non-invasive tumor
bed boost and APBI modality. • Uniquely addresses sources of intra/interfraction motion
with breast immobilization and pre-treatment kV mammography.
– Preliminary studies shown low normal tissue toxicity and favorable cosmetic outcomes.
– NIBB can achieve better cosmetic with delivery of NIBB boost for with WBI.
– Achieve lower doses to the CW, heart and lung
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Ques<ons?