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STEREOTACTIC BODY RADIATION THERAPY

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... beams to treat lesions of the body with 'surgical' doses and high precision ... Timmerman et al, Technology in Cancer Research and Treatment 2003 ... – PowerPoint PPT presentation

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Title: STEREOTACTIC BODY RADIATION THERAPY


1
STEREOTACTIC BODY RADIATION THERAPY
Presented at the Annual Meeting of the
American College of Medical Physics in Orlando,
Florida, May 24, 2005
2
STEREOTACTIC BODY RADIATION THERAPY(SBRT)
  • Part 1 Overview of SBRT
  • (S.H. Benedict, Virginia Commonwealth University)
  • AAPM Task Group 101 SBRT
  • ASTRO Guidelines
  • Part 2 Treatments of the spine with SBRT
  • (Paul Medin, Ph.D., UCLA)
  • Part 3 SBRT in the Conventional Clinical
    Setting
  • Bill Hinson, PhD, Wake Forest University
  • Part 4 KV and MV imaging in SBRT
  • Michael lovelock, PhD, MSKCC

3
EXTRACRANIAL STEREOTACTIC RADIOSURGERY Whats
in a name?
  • ESRT is the use of external beams to treat
    lesions of the body with surgical doses and
    high precision tumor identification and
    relocalization employing stereotactic image
    guidance or implanted fiducials.
  • Extracranial stereotactic ….
  • Radioablation / Radiosurgery / Radiotherapy
  • Surgery vs. Ablation vs. Therapy vs. …
  • According to the chief CPT code developer it will
    be called
  • Stereotactic Body Radiotherapy

4
SBRT REQUIRES
  • Higher confidence in tumor targeting
  • Reliable mechanisms for generating focused,
    sharply delineated dose distributions
  • Reliable accurate patient positioning accounting
    for target motion related to time dependent organ
    movement

5
SBRT why try it?
  • Highly efficient and extremely potent form of
    radiation treatment applicable to a wide variety
    of tumor types
  • Safe and effective for patients with medically
    inoperable primary lung cancer
  • Timmerman R, et al. Chest, 2003.
  • Ongoing investigations for patients with primary
    liver cancer (hepatocellular carcinoma)
  • Extremely common type of cancer worldwide
  • These patients are often unfit for surgery
  • Non-invasive alternative to surgery, RFA, or
    cryosurgery for selected patients with
    oligometastases
  • Especially relevant in era of improving systemic
    targeted therapy
  • Slide courtesy of Brian Kavanagh / University
    of Colorado

6
SBRT what is it?
  • Stereotactically localized, ultra-high-dose
    radiotherapy delivered to discrete tumor nodules
    in the lung, liver, and other extracranial
    locations in a hypofractionated regimen
    (typically 1-5 treatments)
  • The goal is complete cancer cell kill within the
    treated volume
  • Beginning in January, 2005, SBRT will be a
    category III CPT code for billing purposes
  • Slide courtesy of Brian Kavanagh / University
    of Colorado

7
SBRT who started it?
  • Answer Blomgren and Lax, Karolinska Institute,
    Stockholm, Sweden
  • Slide courtesy of Brian Kavanagh / University
    of Colorado

8
SBRT who started it?
Slide courtesy of Brian Kavanagh / University
of Colorado
9
Conventional vs SBRT
Slide courtesy of Brian Kavanagh / University
of Colorado
10
Linear Accelerators with features especially
suitable for SBRT
Slide courtesy of Brian Kavanagh / University
of Colorado
11
SBRT Immobilization/Repositioning
Slide courtesy of Brian Kavanagh / University
of Colorado
12
SBRT how much is enough?
Fowler JF, Tome WA, Welsh JS. Estimation of the
Required Doses in Stereotactic Body Radiation
Therapy. In Stereotactic Body Radiation Therapy,
Kavanagh BD and Timmerman RD, eds. Lippincott
Williams Wilkins, 2005.
Slide courtesy of Brian Kavanagh / University
of Colorado
13
Fowler JF, Tome WA, Welsh JS. Estimation of the
Required Doses in Stereotactic Body Radiation
Therapy. In Stereotactic Body Radiation Therapy,
Kavanagh BD and Timmerman RD, eds. Lippincott
Williams Wilkins, 2005.
Slide courtesy of Brian Kavanagh / University
of Colorado
14
(No Transcript)
15
AAPM Task Group 101 Stereotactic Body Radiation
Therapy
  • The AAPM RTC approved the following charges of
    the task group
  • Charge (1) To review the literature and
    identify the range of historical experiences,
    reported clinical findings and expected outcomes
  • Charge (2) To review the relevant commercial
    products and associated clinical findings for an
    assessment of system capabilities, technology
    limitations, and patient related expectations and
    outcomes.
  • Charge (3) Determine required criteria for
    setting-up and establishing an ESRT facility,
    including protocols, equipment, resources, and QA
    procedures.
  • Charge (4) Develop consistent documentation for
    prescribing, reporting, and recording ESRT
    treatment delivery.

16
AAPM TG 101 SBRT - Table of Contents 1. .
Clinical Rationale for SBRT 2. Review of
Clinical History and Current Use of SBRT (Volker
Steiber) 3. Patient Immobilization,
Relocalization, and Verification 4a. Treatment
Planning and Dosimetry 4b. Treatment plan
evaluation and dose reporting 5. Dosimetry
6. SBRT Treatment Delivery Technology 7.
Clinical Implementation of SBRT 8. Future
directions
17
RADIATION THERAPY ONCOLOGY GROUP (RTOG) 0236 A
Phase II Trial of Stereotactic Body Radiation
Therapy (SBRT) in the Treatment of Patients with
Medically Inoperable Stage I/II Non-Small Cell
Lung Cancer
  • PI Robert Timmerman, MD
  • Eligilibity
  • Patients with T1, T2 ( 5 cm), T3 ( 5 cm), N0,
    M0 medically inoperable non-small cell lung
    cancer
  • Patients with T3 tumors chest wall primary tumors
    only
  • No patients with tumors of any T-stage in the
    zone of the proximal bronchial tree.
  • SBRT dose 20 Gy x 3 fractions

18
RADIATION THERAPY ONCOLOGY GROUP (RTOG)
0236 Dosimetry specifications
  • Zone of the proximal bronchial tree (figure)
  • Target dose homogeneity limits
  • Dose isotropicity limitation requiring falloff
    of approx 50 within 2 cm of PTV
  • V20 lt 10
  • Spinal cord, heart, esophagus, etc. limits

19
SBRT PHYSICS AND TECHNOLOGY
  • 1. CT simulation Assess tumor motion
  • 2. Immobilization Minimize motion, breathing
    effects
  • 3. Planning Small field dosimetry considerations
  • 4. Repositioning High precision patient set-up
  • Fiducial systems, IR/LED Active and Passive
    markers, US, Video
  • 5. Relocalization Identify tumor location in the
    treatment field
  • MV/ KV Xray, Implanted markers and/or set-up
    fiducials
  • Motion tracking and gating systems
  • Real-time tumor tracking systems with
    implanted markers
  • 6. Treatment delivery techniques
  • Adapted conventional systems
  • Specialized SRT Novalis, Cyberknife, Trilogy

20
Clinical Implementation of ESRT
  • These techniques are unusual in the high
    technology realm of radiation treatment in that
    they require more specialized training of
    physicians and physicists rather than specialized
    equipment.
  • Timmerman et al, Technology in Cancer Research
    and Treatment 2003

21
SUMMARY Technical elements of QA
  • The physicist should be responsible for all
    technical QA procedures
  • Imaging equipment
  • Localization and simulation equipment
  • Treatment planning and evaluation system
  • Treatment delivery equipment
  • Treatment verification equipment

22
SUMMARY Clinical elements of SBRT QA
  • A physician and physicist should carry out all
    clinical QA procedures
  • Consistent target volume and organsatrisk
    delineation
  • Quantitative assessment of target and organ
    motion during imaging and treatment
  • Quantitative assessment of setup variation
    during imaging and treatment
  • Patientspecific QA
  • NEED TO ESTABLISH TERMINOLOGY
  • AND REPORTING CONVENTIONS
  • Prescription considerations GTV, margins, dose
    inhomogeneity/uniformity
  • Biological evaluations EUD, NTCP, etc
  • Dose and Fractionation strategy (1 to 5
    fractions, QOD, QD, etc)

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