The technology and uses of on-treatment imaging in radiotherapy
Functional imaging in radiotherapy
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FUNCTIONAL IMAGING IN RADIOTHERAPYVenue: Charles Darwin House, London
CPD: 6 CREDITS
10JULY 2015
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• Room1Primers for the non-specialistsSessionorganisedbyDrDavid
Wilson,ConsultantInterventional
MSKRadiologist,OxfordUniversity
HospitalsNHSTrust
• Room2Radiation protection — current issues in molecular imaging and radiotherapySessionorganisedbyMrAndy
Rogers,HeadofRadiationPhysics,
NottinghamUniversityHospitals
NHSTrust
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• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath
Gnanasegaran,Consultant
PhysicianinNuclearMedicine,
StThomas’Hospital
• Room2Emergency radiology — advances in trauma imaging and Essentials for the radiology traineeSessionorganisedbyDrHardi
Madani,RadiologyRegistrar,Royal
FreeLondonHospitaland
DrAusamiAbbas,Cardiothoracic
RadiologyPostCCT
Day 2Day 1
BIR ANNUAL CONGRESS 20154–5 NOVEMBER
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Day 2
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Programme
09:00 Registration and refreshments
09:30 Welcome and introduction MrJamieDean,PhDStudent,TheInstituteofCancerResearch
09:45 An introduction to functional imaging modalities and what they can tell us DrSimonHughes,ConsultantinRadiologyandNuclearMedicine, NottinghamUniversityHospital
10:15 An introduction to radiotherapy MrChrisBowen,TherapyRadiographer,PlymouthHospitalsNHSTrust
10:45 Refreshments
11:15 Radiobiology for radiotherapy ProfessorKevinPrise,ProfessorofRadiationBiology, Queen’sUniversityBelfast
11:45 Functional MRI and its application to radiotherapy treatment planning DrRafalPanek,MRIPhysicist,RoyalMarsdenNHSFoundationTrustand InstituteofCancerResearch
12:15 MRI and quality assurance DrPeterWright,PrincipalMRPhysicist, SheffieldTeachingHospitalsNHSFoundationTrust
12:45 Lunch
13:45 PET-CT and its application to radiotherapy treatment planning DrRobinPrestwich,ConsultantOncologist,LeedsTeachingHospitals
14:15 PET-CT quality assurance MissLucyPike,ClinicalScientist,King’sCollegeLondonandGuy’sand StThomas’PETCentre
14:45 Radiobiological basis for dose painting DrChrisSouth,RadiotherapyPhysicist,RoyalSurreyCountyHospital
15:15 Refreshments
15:45 Radiotherapy trials utilising functional imaging DrLiamWelsh,ConsultantClinicalOncologist, TheRoyalMarsdenNHSFoundationTrust
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16:15 The role of functional imaging and image registration for assessment of normal lung in thoracic radiotherapy DrRobIreland,LecturerinImageGuidedRadiotherapy, WesternParkHospitalandTheUniversityofSheffield
16:45 Functional imaging for response assessment DrMikePartridge,SeniorGroupLeaderforRadiotherapyPhysics, CRUK/MRCOxfordInstituteforRadiationOncology
17:15 Close of event
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BIR Annual Congress 2015: 4–5 November, London
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Speaker profiles (where supplied)
Mr Chris BowenTherapy Radiographer, Plymouth Hospitals NHS Trust
ChristopherBowenisaTherapyRadiographercurrentlyworkingatthePlymouthOncologyCentreasaTreatmentDeliveryTeamLeadRadiographer.SincegraduatingfromtheSouthWalesSchoolofRadiographyin1994hespentmanyyearsasarotationalRadiographerbuthasspecialisedintreatmentdeliverysince2002.CurrentlyheundertakesspecialisedtreatmentssuchasStereotacticAblativeRadiotherapy(SABR)forlungcancers,CranialStereotactic,VolumetricModulatedArcTherapy(VMAT)andDeepInspirationBreathHold(DIBH).Additionallyhehasexperienceindifferentimagingmodalitiessuchasmegavoltage,kilovoltage,conebeamCTandimplantedmarkermatchingtechniques.
HealsoperformsandfacilitatestrainingforjuniorstaffinimagingandtreatmentdeliveryandistheLeadradiographerforthetruebeamlinearacceleratorandTreatmentFloorRadiationProtectionSupervisor.Hehasapassionforinnovationandimplementationofnewtechniquesanddeliveringhighqualityworldclassradiotherapywithinasmallbuthighlymotivatedandcommittedmultidisciplinaryteam.
Dr Rob IrelandLecturer in Image Guided Radiotherapy, Western Park Hospital and The University of Sheffield
RobIrelandisanacademicmedicalphysicistwithexpertiseinoncologyimageprocessingandclinicaltrials.RobhasbeenconductingradiotherapyimagingresearchanddevelopmentatWestonParkHospitalinSheffieldsince2001andiscurrentlyaLectureronImageGuidedRadiotherapyattheUniversityofSheffield.Robhaspublished20academicpapers,over90abstractsandhasreceivednumerousgrants,includingfundingfromCRUKandNIHR.ThemainthemesofRob’sresearchfocusonradiotherapyapplicationsofimageregistration,validationofventilationCT,andaninvestigationoftheroleofgasandprotonMRIinlungcancertreatmentplanningandpost-treatmentevaluation.
Dr Rafal PanekMRI Physicist, Royal Marsden NHS Foundation Trust and The Institute of Cancer Research
RafalPanekisanMRIPhysicistconductingresearchinthefieldoffunctionalMRIattheRoyalMarsdenNHSFoundationTrustandTheInstituteofCancerResearch.HiscurrentresearchfocusisanevaluationofparametersdefinedbydynamiccontrastenhancedMRI,bloodoxygenleveldependentMRIanddiffusionweightedMRIaspredictivebiomarkersofpooroutcomeinheadandneckpatientsandpreclinicalin vivostudies.DrPanekcollaborateswiththeMRIteamwithintheCancerResearchUK
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CancerImagingCentreattheInstituteofCancerResearchandtheHeadandNeckclinicalteamattheRoyalMarsdenHospital,whichprovidesauniqueopportunitytoinvestigatetechniquesthatcanbeeffectivelytranslatedforthemanagementofpatients.
Dr Mike PartridgeSenior Group Leader for Radiotherapy Physics, CRUK/MRC Oxford Institute for Radiation Oncology
MikePartridgehasbeenworkinginmedicalimagingandradiotherapyresearchfornearly20years.HestudiednaturalsciencesatCambridgeUniversityandobtainedaPhDinimagingatCranfieldUniversitybeforeworkingasapostdoctoralscientistattheInstituteofCancerResearch,TheRoyalMarsdenHospitalandtheGermanCancerResearchCentreinHeidelberg.HemovedtoOxfordUniversityin2012tostartanewresearchgroupinradiotherapyphysics.Hiscurrentresearchfocusesonfunctionalimaginginradiotherapywithaparticularfocusonunderstandingthepotentialroleofhypoxiaimaging.Thisrangesfromcharacterisingheterogeneityatacellularlevelanddevelopingmathematicalmodelsthatlinkhypoxia,imagingandradiationresponsetoclinicalstudiesinvestigatingfunctionalimagingtopredictearlyresponsetotherapy.Whennotatworkheenjoysbirdwatchingandwalking.
Miss Lucy PikeClinical Scientist, King’s College London and Guy’s and St Thomas’ PET Centre
LucyPikeisaClinicalScientistattheKing’sCollegeLondonandGuy’sandStThomas’PETCentre,London.HercurrentroleinvolvesprovidingsupportforclinicalandresearchapplicationsofPET-CTincludingtheuseofnovelPETtracersandcompleximagingtechniques.InadditiontothisshemanagestheNationalCancerResearchInstitutePETCoreLab,whichprovidestechnicalsupportanddevelopsstandardsforPETimaginginmulticentreclinicaltrials.AspartoftherequirementforstandardisationinmulticentreclinicaltrialsinvolvingPET,shehasbeeninvolvedindevelopingaqualityassuranceprogramforinclusionofPETintoradiotherapytreatmentplanning.
Dr Robin PrestwichConsultant Oncologist, Leeds Teaching Hospitals
RobinPrestwichtrainedinmedicineatOxfordUniversitygraduatingin1998.HistraininginClinicalOncologywasbasedinLeedsandhegainedhisFRCRin2006.HecompletedaPhDasaCRUKClinicalTrainingFellowin2009exploringtheroleoftheimmuneresponseinoncolyticvirotherapy.FollowingcompletionofhistraininginClinicalOncologyin2011,hecompleteda1yearfellowshipintheDepartmentofNuclearMedicinewithhisresearchprimarilyrelatingtotheroleofPETforradiotherapyplanning.HehasbeenaConsultantinClinicalOncologysince2012andisthechiefinvestigatorofthreelocalstudiesexploringmultimodalityimagingforradiotherapyplanninginheadandneckcancerandlymphoma.
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Professor Kevin PriseProfessor of Radiation Biology, Queen’s University Belfast
KevinPriseisProfessorofRadiationBiologyandDeputyDirectorattheCentreforCancerResearchandCellBiology,Queen’sUniversityBelfast,wherehehasbeensince2007.PriortothishewasHeadoftheCellandMolecularRadiationBiologyGroupattheGrayCancerInstituteinNorthwood,London.AbiochemistrygraduateofAberdeenUniversity,hehaswideranginginterestsinradiationbiologyincludinglowdose,radiationqualityandcellsignallingmechanisms.Hisrecentstudieshavebeenfocusedondevelopingnewbiological-basedmodelsforoptimisingadvancedradiotherapiessuchasintensitymodulatedradiotherapyandparticletherapies.Hehasover250publications.
Dr Chris SouthRadiotherapy Physicist, Royal Surrey County Hospital
ChrisSouthhasrecentlytakenuptheroleofheadofradiotherapydosimetryatStLuke’sCancerCentre,Guildford.FromAugust2012toJune2015hewasdeputyheadoftreatmentplanningatStLuke’s,priortowhichhespentoveradecadeasaclinicalradiotherapyphysicistattheRoyalMarsdenHospitalinSutton.In2005hebeganapart-timePhDattheInstituteofCancerResearchon“TheUseofFunctionalImagingtoDesignOptimalRadiotherapyDoseDistributions”,graduatingin2011.HehasbeenaregisteredClinicalScientistsince2005andhasanMScinMedicalPhysicsfromtheUniversityofSurrey(2001)andanMPhysfromOxfordUniversity(1998).Publicationsinclude“Atheoreticalframeworkforprescribingradiotherapydosedistributionsusingpatient-specificbiologicalinformation”(Southet al, Med. Phys.2008)and“Doseprescriptioncomplexityversustumourcontrolprobabilityinbiologicallyconformalradiotherapy”(Southet al, Med. Phys.2009).
Dr Liam WelshConsultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust
LiamWelshreadphysicsattheUniversityofCambridgeandstayedontoresearchaPhDinstructuralbiophysicswithRichardPerhamandDonMarvinintheBiochemistryDepartment.AfteraperiodasaWellcomeTrustpost-docinRichardPerham’slab,LiamleftacademiatotraininmedicineatGuy’s,King’sandStThomas’MedicalSchool,graduatingwithhonoursin2004.AftergeneralmedicaltrainingatStBart’sandtheRoyalFreeHospital,LiammovedtotheRoyalMarsdenHospitaltotraininClinicalOncology.DuringhisSpRtrainingLiamspenttwoyearsasaclinicalresearchfellowwithintheHeadandNeckUnitattheRoyalMarsdenworkingonfunctionalMRIinheadandneckcancer.LiamwasappointedasaConsultantClinicalOncologistinNeuro-oncologyattheRoyalMarsdenin2015,andretainsaresearchinterestinfunctionalimaging.
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Dr Peter WrightPrincipal MR Physicist, Sheffield Teaching Hospitals NHS Foundation Trust
PeterWrightisthePrincipalMRPhysicistatSheffieldTeachingHospitalsNHSFoundationTrustafterpreviouslybeingattheUniversityHospitalofNorthMidlandswherehesupportedthecommissioningofthreenewSiemensMRsystemsandsubsequentprotocolsetupandimagequalityimprovement.PriortotheUniversityHospitalsofNorthMidlands,Peterspent3yearsasthein-housephysicistatLeedsMusculoskeletalandBiomedicalResearchUnit(LMBRU),aNationalInstituteforHealthResearchfundedunitatLeedsNHSTrust.Thisroleincludedhisclinicalmedicalphysicstraining.PriortothisheobtainedhisPhDattheUniversityofNottinghaminfunctionalMRIandrelatedparametersusing7Tand3TMRIsystems.
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Abstracts (where supplied)
An introduction to radiotherapy Mr Chris Bowen
Radiotherapyisahighlyspecialised,andeffectivetreatmentfortreatingcancer,howeveritcancauseseriousacuteandchronicsideeffectsincludinginducingsecondmalignancies.Owingtothisrisktheuseofionisingradiationisstringentlymonitoredtobeassafeaspossibleallowingdeliveryofoptimisedhighdosestotargetvolumeswhilesparingnormalhealthytissue.Inordertodothisradiotherapytreatmentsneedtobeextremelyaccuratetoreducerisktopatients.
Radiotherapyplanningreliesontheuseofdifferentimagingmodalitiestoprovideasaccurateapictureaspossibleofthetargetvolumerequiringtreatment.InturnRadiotherapytreatmenthastobedeliveredpreciselyandconsistently.Patientpositioningandmonitoringiskeytothereproducibilityoftreatments.
Manyfactorscaninfluencetheaccuracyoftreatmentdeliverybuttherearepracticalwaystominimisetheimpactofthesefactors.ThistalkaimstoprovideabasicintroductiontoRadiotherapyforaudiencememberswhoarenotconversantwiththedisciplineofRadiotherapy.
Educationalaims:• Todeliveranintroductiontoradiotherapyandpatientpathway• Presenttheadvantages,disadvantagesandbenefitsofradiotherapy• Outlinetheradiotherapypatientpathwayanddifferentdeliverymethodsof
radiotherapy• Definevolumesusedtodelineatetreatmenttargetareas• Highlightimportanceforconsistencyandaccuracyinradiotherapyplanningand
treatment• Provideinsightintohowdailypositionalaccuracyisassessedandmonitoredby
differentimagingmethods• Highlightsomeofthemajorissuesaffectingpatientposition• Discusspotentialinnovativedevelopmentsinradiotherapy
Learningobjectives:• Toprovidetheaudiencewithabriefandbasicintroductiontothenatureof
radiotherapytreatments• Demonstratethenecessityforaccurateandreproduciblepositioningfor
radiotherapypatients• Demonstratetheneedforgoodimaginginterpretationandprotocols
Radiobiology for radiotherapyProfessor Kevin Prise
Radiationbiologycontributestoradiotherapybyprovidingtheconceptualbasisforitsuseandprovidingrationaleforthedevelopmentofnewapproachesandtheschedulingchoicesthatneedtobemadeforitsdelivery.Underpinningthis
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arethe“5Rs”ofradiationbiologywhichincludeintrinsicradiosensistivity,repair,repopulation,reassortmentandreoxygenation.Cancerisdefinedbyaseriesofhallmarksthatdifferentiatetumoursfromthecontrolledgrowthandmetabolismofnormaltissues.Manyofthesehallmarksleadtodifferencesintumoursthatimpactonradiobiologicalmechanismsandcanbeaccessedbyfunctionalimagingfortargetedradiotherapiesforbothclinicalandpreclinicalstudies.Thisoverviewlecturewillgiveanunderstandingofsomeoftherelevantconceptsfromradiobiology.
Educationalaims:• Reviewthebasicradiobiologicalprinciplesunderpinningradiotherapy• Reviewtheroleoffunctionalimagingfromaradiobiologicalperspective
Learningobjectives:• Understandthekeyhallmarksofcancer• Understandthe“5Rs”ofradiobiology
Furtherreading:• HanahanDandWeinbergR.A,(2011),Hallmarksofcancer:thenextgeneration.
Cell144,646-74• BossMK1,BristowR,DewhirstMW.(2014),Linkingthehistoryofradiation
biologytothehallmarksofcancer.RadiatRes.181,561-77.• BasicClinicalRadiobiology4thEdition,(EdsM.C.JoinerandA.VanderKogel)
ArnoldHodder2009
Functional MRI and its application to radiotherapy treatment planningDr Rafal Panek
Inadditiontohigh-resolutionmorphologicalimagesprovidingexcellentsofttissuecontrast,MRIcanalsobeusedtoobtaininformationonthefunctionalpropertiesoftissues.Thesetechniquesexploitpathophysiologicalchangesoccurringwithintumoursastheircontrastmechanism,suchasalteredperfusion,cellularityorbloodoxygenationlevel.Therefore,functionaltechniquesareincreasinglybeingusedfortumourdetection,monitoringoftreatmentresponse,anddetectionofrelapseddisease.FunctionalMRImethodssuchasdiffusionweightedimaging(DWI)andbloodoxygenleveldependentMRI(BOLD)arefunctionaltechniquesbasedontheendogenouscontrastinthetissue,whileotherssuchasdynamiccontrastenhanced(DCE)ordynamicsusceptibilitycontrast(DSC)arebasedonexogenousgadoliniumbasedcontrastagents.Intheradiotherapycontexttheultimategoaloffunctionalimagingistoidentifyradio-resistantdiseaseandthusprovideabiologicaltargetvolumefordoseboostingoralternativetreatment.Itcanalsobeusedtovisualizeorgansatriskandiswidelyusedtoidentifynervefibres,whichcanbeusefulforregionalsparing.GeometricaccuracyisthereforeessentialtoallowcorrectregistrationoffunctionalMRimageswithanatomicalMRIandCTdatasets.TheneedforpatientimagingintheradiotherapytreatmentpositionposesadditionalchallengesandrequiresdevelopmentofMRI-compatibleimmobilizationsetupsandRFcoilconfigurations.
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ThispresentationwillcoveranintroductiontofunctionalMRImethods,examplesofmethodimplementationinthecontextofRTplanning(clinicaltrials)andchallengesinfunctionalMRI.
Learningobjectives:• TounderstandwhatfunctionalinformationcanbeobtainedusingMRI• TounderstandmainlimitationofmethodimplementationforRTplanning
Furtherreading:• PadhaniAR,LiuG,KohDM,ChenevertTL,ThoenyHC,TakaharaT,Dzik-
JuraszA,RossBDetal.Diffusion-WeightedMagneticResonanceImagingasaCancerBiomarker:ConsensusandRecommendations,Neoplasia2009;11(2):102-125.
• GalbánCJ,ChenevertTL,MeyerCR,TsienC,LawrenceTS,HamstraDA,JunckLetal.Theparametricresponsemapisanimagingbiomarkerforearlycancertreatmentoutcome.Naturemedicine,2009;15(5):pp.572-6.
• O’ConnorJPB,JacksonA,ParkerGJM,JaysonGC.DCE-MRIbiomarkersintheclinicalevaluationofantiangiogenicandvasculardisruptingagents.BritishJournalofCancer2007;96:189–195.
• NuytsS.Definingthetargetforradio-therapyofheadandneckcancer.CancerImaging2007;7:S50–S55.
• NewboldK,PartridgeM,CookG,SohaibSA,Charles-EdwardsE,Rhys-EvansP,etal.Advancedimagingappliedtoradiotherapyplanninginheadandneckcancer:aclinicalreview.BrJRadiol.2006Jul1;79(943):554–61.
• WelshL,PanekR,McQuaidD,DunlopA,SchmidtM,RiddellA,KohDMetal.Prospective,longitudinal,multi-modalfunctionalimagingforradicalchemo-IMRTtreatmentoflocallyadvancedheadandneckcancer:theINSIGHTstudy.RadiatOncol.2015May15;10(1):112.
• WangD,DoddrellDM.Geometricdistortioninstructuralmagneticresonanceimaging.CurrentMedicalImagingReviews2005;1:49-60.
• MetcalfeP,LineyGP,HollowayL,WalkerA,BartonM,DelaneyGP,VinodS,TomeW.ThepotentialforanenhancedroleforMRIinradiation-therapytreatmentplanning.TechnolCancerResTreat.2013Oct;12(5):429-46.
• vanderHeideUA,HouwelingAC,GroenendaalG,Beets-TanRGH,LambinP.FunctionalMRIforradiotherapydosepainting.Magneticresonanceimaging.ElsevierInc;2012Nov1;30(9):1216–23.
MRI and quality assuranceDr Peter Wright
TheMRIscannerisinitsveryanatureacomplexmachine,whichmeansthatwhengremlinsdogetintothesystemitcanbeveryhardtopinpointtheexactproblemquicklyandreturntheequipmenttoclinicaluse.Bysettingupandrunningarobustqualityassurancescheme,anyissueswiththeMRsystemwillbehighlightedatanearlystageandpotentiallyaidthemanufacturerengineersinidentifyingthespecificissueandallowaspeedyresolution.
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ThistalkwillaimtohighlightwhatdeterminesimagequalityinMRandhowtheseparametersaremeasuredthroughqualityassuranceusingthemostcommonlyavailablephantoms.Finally,afewofthemostcommonartefactswillbepresented.Ofthoseartefactsproducedbyphysiologicaleffects,wewilldiscusshowtheseartefactscanbereduced.
Educationalaims:• ExaminethecomponentsofanMRsystem• Discusscontributorstoimagequality• ExamineparametersmeasuredaspartofaQAprocedureandavailable
phantoms• ReviewofartefactsseeninMRIandtheircause
PET-CT and its application to radiotherapy treatment planningDr Robin Prestwich
TherehasbeenanexplosionofinterestinthepotentialuseofPET-CTforradiotherapyplanning.Themajorityofworkhasfocussedon18F-fluoro-2deoxyD-glucose(FDG)althoughthereisinterestinimagingmultiplebiologicalprocesseswithnovelPETtracers.PET-CTmayhavearolein3keyareasofradiotherapyplanning:targetselection,tumourdelineation,treatmentindividualisationandadaptation.Intermsoftargetselection,PEThasacomplimentaryroletoanatomicalimagingforsometumourtypesalthoughforsometumoursitesnosuperiorityofPEThasbeendemonstrated;itisnecessarytobeawareofthepossibilityoffalsepositiveandnegativeresults.WithregardtotheuseofPETforcontouring,thequestionofwhetheritispossibletouseaqualitativediagnosticimagingmodalityforquantitativetumouredgedelineationremainscontroversial.MultiplemanualandautomatedalgorithmsforcontouringareasofPETavidityhavebeenproposed.Pathologicalvalidationisonlyavailableinalimitednumberofreportedseries.TheabilityoffunctionalimagingwithPETtoevaluatetumourheterogeneity/biologybothspatiallyandtemporallyhasledtointerestintheuseofPETimagingasanimagingbiomarkertoguideapproachestotreatmentindividualisation/adaptation.Significantchallengesremainpriortoadoptionintoclinicalpractice.
Educationalaims:• TolearnaboutthepotentialroleofPETinradiotherapyplanningfortarget
selection• TolearnaboutthepotentialroleofPETinradiotherapyplanningfortumour
contouring• TolearnaboutthepotentialroleofPETasanimagingbiomarkertoallowthe
individualisationoftreatment/on-treatmentadaptation
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PET-CT quality assuranceMiss Lucy Pike
PETisincreasinglyusedfordiseasestaging,therapymonitoringandfollowupforarangeoftumourtypesinroutineclinicalmanagement.InmanytumourtypesPETcanprovidegreatersensitivityandspecificityfornodalstagingthanCTorMRandcandetectfunctionalchangesmuchearlierthananatomicalchanges.TheadditionalfunctionalinformationfromPETcancomplementtheanatomicaldataprovidedbyCTandthereismuchinterestinincorporatingthisintoradiotherapyplanningtohelpmoreaccuratelydefinetreatmentvolumesandpotentiallyreduceradiationdosestohealthytissue.ThereisanincreasingcasetosupporttheinclusionofFDG-PETinradiotherapyplanningforsometumourtypes,butinappropriateuseofPETtoreducetreatmentvolumescouldimpairratherthanimprovepatientoutcomes.ItisimportantthereforethatasolidevidencebaseisestablishedthroughclinicaltrialstodeterminehowPETimagingisbestutilisedinradiotherapyplanning.
EvaluationofvolumedelineationtechniquesincorporatingPETversusconventionalcontouringtechniquesinradiotherapyshouldbecarefullyplannedandexecutedthroughclinicaltrialsincorporatingrigorousandconsistentqualitycontrolandimagingprotocols.ThistalkaimstooutlinetheprocessesinvolvedinincorporatingPETintoradiotherapyplanninganddiscussessomeofthetechnicalchallengesthatmaybeencountered.InparticularthisdrawsonourownexperienceofdevelopingPET-CTprotocolsandthepatientpathwayforaphaseIFDG-guideddoseescalationstudy.
Educationalaims:• ToprovideanoverviewofthetechnicalrequirementsforincorporatingPET-CT
intoradiotherapyplanning• TodiscussthepracticalissuesofincorporatingPET-CTintoradiotherapy
planning
Learningobjectives:• Identifythestepsinvolvedinsettingupaqualityassuranceprogramforuseof
PETinradiotherapy• Identifythepotentialsourcesoferrorandhowtominimisethemthrough
rigorousQCtests
Referencesandcitations:• SomerEJ,PikeLC,MarsdenPK.RecommendationsfortheuseofPET
andPET-CTforradiotherapyplanninginresearchprojects.BritJRadiol.2012;85(1016):e544-8.
• ThomasCM,PikeLC,HartillCE,BakerS,WoodsE,ConveryDJ,etal.SpecificrecommendationsforaccurateanddirectuseofPET-CTinPETguidedradiotherapyforheadandnecksites.MedPhys.2014;41(4):041710.
• BoellaardR,Delgado-BoltonR,OyenWJ,GiammarileF,TatschK,EschnerW,etal.FDGPET/CT:EANMprocedureguidelinesfortumourimaging:version
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2.0.EurJNuclMedMolImaging.2015;42(2):328-54.Furtherreading:• SattlerB,LeeJA,LonsdaleM,CocheE.PET/CT(andCT)instrumentation,
imagereconstructionanddatatransferforradiotherapyplanning.RadiotherOncol.2010;96(3):288-97.
• ThorwarthD,BeyerT,BoellaardR,DeRuysscherD,GrgicA,LeeJA,etal.IntegrationofFDG-PET/CTintoexternalbeamradiationtherapyplanningTechnicalaspectsandrecommendationsonmethodologicalapproaches.Nuklearmedizin-NuclearMedicine.2012;51(4):140-53
Radiobiological basis for dose paintingDr Chris South
Traditionallyakeyaiminradiotherapytreatmentplanninghasbeentodeliverauniformhighdosetoatumour.However,tumoursareknowntobebiologicallyheterogeneous,withvariationsinanumberoffactorsknowntoinfluenceradiationresponse.Modernmedicalimagingtechniquescanprovideinformationonthespatialdistributionofmanyofthesebiologicalparameters.Technologicaladvancesinradiotherapyallowcomplexdosedistributionstobecalculatedanddeliveredwithunprecedentedprecision.Itisthereforepossibletodesignnon-uniformdoseprescriptionsbasedonfunctionalimages,preferentiallytargetinghigherdosestotumourregionsathighestriskofrecurrence,aprocessknownasdosepainting.
Avarietyofmethodshavebeenproposedforlinkinglocaltargetdosetoimageintensity.Ingeneral,amodeldescribingtheradiobiologicalsignificanceoftheimagedataisusedtooptimiseanon-uniformtargetdosedistribution.Theefficacyofsuchmethodswilldependontheaccuracyoftheinterpretationandquantificationofimagesaswellasthecorrectnessoftheradiobiologicalmodel.
Dosepaintingistechnicallyfeasibleusingawiderangeofimagingmodalitiesandplanningtechniques.Uncertaintiesinimageinterpretationandradiobiologicalmodellingshouldbetakenintoaccountwhenpredictingtheefficacyofagivenmethod.
Educationalaims:• Tooutlinetheprinciplesofandrationalefordosepainting• Todescribetherelativeimportanceofvariousbiologicalandradiobiological
parameters• Tocompareandcontrastarangeofdifferentapproachestodosepainting
Learningobjectives:• Gainanappreciationoftherangeofimagingmodalitiesandmarkerswhich
maybeusedindosepainting• Gainanawarenessofthestrengthsandweaknessesofavarietyofmethods
forgeneratingtargetdosedistributionsfromfunctionalimages
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The role of functional imaging and image registration for assessment of normal lung in thoracic radiotherapy Dr Rob Ireland
Educationalaims:• Toreviewfunctionalimagingofnormallungtissueinpatientswithlung
cancer• Tointroduceexamplesofimageregistrationapplicationsforlunganalysis
Learningobjectives:• TolearnaboutnovelapplicationsofSPECT,MRIandCTthatprovide
ventilationandperfusioninformationtoassistwiththeplanningandevaluationofradiotherapy
Aimsofimagingthe‘normal’lung:• Radiotherapyplanning:reducethedosetonormallungtissue• Evaluationoftreatment:assessradiationinduceddamagetonormallung
Methods:• SPECT:e.g.papersbyLawrenceMarks,MikePartridgeandKonstantin
Lavrenkov• HyperpolarisedgasMRI:PapersbyRobIrelandandJimWild• VentilationCT:PapersbyThomasGuerrero,RichardCastillo,Tokihiro
Yamamoto• VentilationMRI?SeveralpapersbyGrzegorzBauman
Results/findings:• Potentialreductionofdosetonormallungtissuedemonstratedinseveral
papers• Potentialidentificationofradiationinducedlungdamagealsodemonstrated
Keypoints/conclusions:• Reductionofdoseandidentificationofradiationdamageinlungcancer
patientshasbeeninvestigatedwithavarietyofimagingmodalities.Challengesstillexistbeforesuchtechniquescanbeusedroutinely
Referencesandcitations:• IrelandRH,etal.2007Feasibilityofimageregistrationandintensity-
modulatedradiotherapyplanningwithhyperpolarizedhelium-3magneticresonanceimagingfornon-small-celllungcancer.IntJRadiatOncolBiolPhys68273-81
• MarksLBetal.1997Physicalandbiologicalpredictorsofchangesinwhole-lungfunctionfollowingthoracicirradiation.IntJRadiationOncologyBiolPhys39563-570
• MunleyMT,MarksLBetal.1999Multimodalitynuclearmedicineimaginginthree-dimensionalradiationtreatmentplanningforlungcancer:challengesandprospects.LungCancer23105–114
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• SimonBA2000Non-invasiveimagingofregionallungfunctionusingx-raycomputedtomography.JClinMonitComput200016433-42
• VinogradskiyYY,etal.2012Useofweekly4DCT-basedventilationmapstoquantifychangesinlungfunctionforpatientsundergoingradiationtherapyMedPhys39289-98
Furtherreading:• PartridgeM,etal.2010Imagingofnormallung,liverandparotidgland
functionforradiotherapyActaOncol49997-1011• SimonBA,etal.2012Whatcancomputedtomographyandmagnetic
resonanceimagingtellusaboutventilation?JApplPhysiol113647-57
Functional imaging for response assessment Dr Mike Partridge
Medicalimaginghasforalongtimeplayedanabsolutelycentralroleinradiotherapy,withx-RayCTbeingusedtoaccuratelyoptimisetreatmentsemployingpatient-specificanatomy.However,magneticresonanceimaging(MRI)andpositronemissiontomography(PET)enableustomapnotjustpatientanatomybutalsophysiologicalfunction,givingimportantinformationaboutthebiochemistryoftumoursinadditiontotheirphysicalcharacteristics(sizeandlocation).Forexample,weknowthatregionsoftumoursthathavelowoxygenlevels(hypoxic)offerresistancetobothradiotherapyandchemotherapy.
Byimaginghypoxictumourregionswecanmonitorresponsetotherapyand,forpatientswhodonotappeartoberespondingtoatreatment,eitherescalateradiationdoseoraddahypoxia-modifyingdrug(orboth).Dynamiccontrast-enhanced(DCE)anddiffusion-weighted(DW)MRIcanbeusedtomapbloodflowandperfusionand/ordiffusionpropertiesintissue,tellingusaboutoxygensupply.PETcanbeusedtomapglucosemetabolismusingfluorine-18labelledfluorodeoxyglusoce(18F-FDG)andhypoxiausingfluoromisonidazole(18F-FMISO).
Thereisgrowingevidencethatimagingchangesinearlyfunctionalresponsemayenablemoreaccuratepredictionofoutcomeinaspecificpatientthanjusttheirpre-treatmentimages.However,wedonotyetknowwhatthebestimagingmodalitytouseis,whattheoptimumtime-pointtoobserverresponseis,orwhetherimagingwithmorethanonemodalitywilladdadditionalinformation.
InthislecturewewillreviewsomeoftherecentlypublishedworkshowingtheuseofdwMRIandFMISOPETforearlyresponsepredictionanddiscusshowthisinformationmightbeusedinbiologically-adaptiveradiotherapyworkflows.
Educationalaims:• Togiveabriefoverviewofcurrentpublishedworkdemonstratingtheuseof
functionalimagingtoassessresponsetotreatment• Toillustratehowearlyresponseassessmentmightbeincorporatedinto
strategiesforbiologically-adaptivetreatment
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Learningobjectives• Tolearnaboutcurrentpublishedworkdemonstratingtheuseoffunctional
imagingtoassessresponsetotreatment• Tolearnabouthowearlyresponseassessmentmightbeincorporatedinto
strategiesforbiologically-adaptivetreatment
Referencesandcitations:• Lambrecht,M.,etal.(2010).“Roleandvalueofdiffusion-weightedMRIin
theradiotherapeuticmanagementofheadandneckcancer.”ExpertRevAnticancerTher10(9):1451-1459.
• Hoeben,B.A.,etal.(2013).“18F-FLTPETduringradiotherapyorchemoradiotherapyinheadandnecksquamouscellcarcinomaisanearlypredictorofoutcome.”JNuclMed54(4):532-540.
• Zips,D.,etal.(2012).“Exploratoryprospectivetrialofhypoxia-specificPETimagingduringradiochemotherapyinpatientswithlocallyadvancedhead-and-neckcancer.”RadiotherOncol105(1):21-28.
• Tran,L.B.,etal.(2015).“Predictivevalueof(18)F-FAZAPETimagingforguidingtheassociationofradiotherapywithnimorazole:Apreclinicalstudy.”RadiotherOncol114(2):189-194.
Furtherreading:• Jaffray,D.A.(2012).“Image-guidedradiotherapy:fromcurrentconceptto
futureperspectives.”NatRevClinOncol9(12):688-699.
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Philipsisadiversifiedhealthandwell-beingcompanyandaworldleaderinhealthcare,lifestyleandlighting.Ourvisionistomaketheworldhealthierandmoresustainablethroughmeaningfulinnovation.
Wedevelopinnovativehealthcaresolutionsacrossthecontinuumofcare,inpartnershipwithcliniciansandourcustomerstoimprovepatientoutcomes,providebettervalue,andexpandaccesstocare.
Aspartofthismissionwearecommittedtofuellingarevolutioninimagingsolutions,designedtodelivergreatercollaborationandintegration,increasedpatientfocus,andimprovedeconomicvalue.Weprovideadvancedimagingtechnologiesyoucancountontomakeconfidentandinformedclinicaldecisions,whileprovidingmoreefficient,morepersonalisedcareforpatients.
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TheSiemensHealthcaresectorisoneoftheworld’slargestsupplierstothehealthcareindustryandatrendsetterinmedicalimaging,laboratorydiagnostics,medicalinformationtechnologyandhearingaids.Siemensoffersitscustomersproductsandsolutionsfortheentirerangeofpatientcarefromasinglesource–frompreventionandearlydetectiontodiagnosis,andontotreatmentandaftercare.Byoptimisingclinicalworkflowsforthemostcommondiseases,Siemensalsomakeshealthcarefaster,betterandmorecost-effective.
www.siemens.co.uk/healthcare
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