Real Time Ultrasound Guidance for Optimizing High Dose...
Transcript of Real Time Ultrasound Guidance for Optimizing High Dose...
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Real Time Ultrasound Guidance
for Optimizing High Dose Rate
Prostate Brachytherapy
Bruce Libby, PhD
University of Virginia Health
System
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Conflicts of Interest
• Royalties from UpToDate.com
• Shareholder in Varian, Inc.
• Non-disclosure agreement with Varian
Brachytherapy
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My neighborhood bear
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Timeline of Events
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August 1, 2012- Timothy
Showalter, MD starts at UVa
with HDR”
“I want to do partial prostate brachytherapy
with sharks with lasers
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Timeline cont’d
• Varian introduces Vitesse 3.0- Dec 2012
• Invitation to give this talk- Feb 2013
• Receive Vitesse 3.0- March 2013
• Acceptance testing, commissioning, dry
runs, “buttonology”- April- August 2013
• First treatment ???????
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IGBT Suite at UVa anesthesia
equipment
Trumpf OR table
OR lights
Siemens
Somatom
Sliding
Gantry CT
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Scan-Plan-Treat Workflow at UVa (time from CT scan to initiation of treatment)
• vaginal cylinder ~ 13 minutes
• T&O ~ 25 minutes
• Gyn Interstitial ~ 1 hour
• (Contura-can place, scan, plan, & treat
within ~2 hours)
• HDR Prostate Brachytherapy-????
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Why prostate HDR?
• optimization (can compensate for poor
placement of the needles)
• fewer radiation safety concerns
• no post plan
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Why Ultrasound Based Treatment
Planning?
• WYSIWYG (better visualization of base
and apex of the prostate)
• Real time visualization of needle insertion
• Obviate the need to move the patient for
CT or MR
• Works well in a scan-plan-treat
environment (we have experience in
maintaining patients under anesthesia
during planning and treatment)
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Intro to Vitesse 3.0
Variseed BrachyVision
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Vitesse Variseed-like menu
HDR source
activity
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Dry-run set up
Civco EXII stepper prostate phantom
B&K flex
focus
ultrasound
Vitesse laptop
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Ultrasound Capture
manual capture
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Ultrasound Capture
Tracked stepper capture
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Ultrasound Capture
twister capture
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Needle Identification
Place needles in plan where you
think they may be used
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Preinsertion of Needle (live display)
Sagittal View (live) transverse view-focus on
needle of interest
scan plane
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Needle Inserted needle flash is within the planned path
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What if inserted needle does not overlie
the planned needle?
inserted
planned
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adjust the planned position (can be done
with bent needles as well)
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Optimization Optimization Parameters similar to BrachyVision
Live DVH and dwell time display
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Isodose and Dwell Control Window
Variseed-like
BrachyVision-like
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QA
• Ensure proper transfer guide tube
placement
• Measure needle + transfer tube lengths
• Dose second check
• Transfer plan to HDR Treatment Console
• Check treatment parameters
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Dose second check
Excel spreadsheet reads in dwell positions and times,
recalculates dose to dose points
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Partial prostate HDR
• used for low risk patients
• dosimetry can be optimized to spare
adjacent structures
• CTV can be based on MRI
• US guided partial prostate HDR can be
used to spare urethra, rectum
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CT-on-Rails-Guided Partial Prostate HDR Brachytherapy:
A Therapeutic Alternative to Reduce Morbidity and
Overtreatment for Low-Risk Prostate Cancer
PI: Timothy N. Showalter, MD (Department of Radiation
Oncology)
Grant to be Submitted
Ultrasound
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Ultrasound/MR fusion
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Other Uses
Tumor
Vaginal
Dilator
Rectum
Syed Implant
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Points to Ponder
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Points to Ponder (cont’d)
• Patient Selection
• Ultrasound in place for treatment?
• Database Management
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BrachyVision Vitesse BeBig Eye Plaque VariSeed
Brachytherapy Planning Systems
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Vitesse User’s Guide:
“Vitesse is intended for use by
an expert user....Besides having professional
certification, users shall be fully trained
in HDR brachytherapy procedures,
transrectal ultrasound brachytherapy,
and the Vitesse application”
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In case of problems...
do a CT scan and plan in BrachyVision
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Conclusions
• Vitesse 3.0 is a full treatment planning system for ultrasound guided prostate HDR
• optimized for use with existing equipment (B&K ultrasound, Civco tracked steppers)
• can be integrated into a scan-plan-treat IGBT workflow
• all caveats are presumed- correct source activity, acceptance testing, commissioning and training
• can fuse with MR for partial prostate HDR
• some utility for gynecological treatments (???)
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Acknowledgements
• Varian Brachytherapy- Wayne Lajoie,
Karen Kigin, Rebecca Park, Sophie
Weatherall
• Multiple Varian Webinars on
MyVarian.com
• Paul Bagli- Civco
• Jerry Fiddes- B&K Medical
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“A boy loves his dog”- Harlan Ellison