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Dustin Melancon DOS 524 - Conformal Treatment Planning Conformal Terms Discussion April 7, 2013 Term #1: Tumor control probability (TCP) The tumor control probability (TCP) can show the effectiveness of a given treatment. It is defined as, The probability that a tumor is eradicated after a given time under a certain treatment schedule, given its initial size.1 In other words, its the probability of local control according to the planned dose distribution. Munro and Gilbert introduced the TCP concept in 1961. When initially determining dose, the calculations did not include inhomogeneities. There are more complex models today that include many factors such as non-uniform tumor doses, volume effects, and alternate fractionation schemes.2 The ratio of normal cells to tumor cells can be considered the therapeutic ratio for radiation oncology. I think its easiest to visualize TCP when its represented by two sigmoid curves, one for the TCP and the other for the normal tissue complication probability (NTCP). The best radiation treatment for a tumor maximizes the TCP and minimizes the NTCP.3

Source: http://ars.els-cdn.com/content/image/1-s2.0-S0887217110000892-gr4.jpg Issues can arise when making a direct use of TCP models because tumor regression during therapy is common except for slow growing diseases, such as breast or prostate cancer. Differences in heterogeneity, tumor cell radiosensitivity, hypoxia, numbers of cancer cells, and rate of cancer cell reproduction also make models less predictive for a particular patient.4 We can try to think of it in terms of an effective volume. When we irradiate a target to the

prescription dose, we can see a nonuniform dose distribution. Models for computing NTCPs of nonuniformly irradiated organs have been proposed, but the current biologic response data for many tissues is unreliable and poorly documented. Treatment plans should be evaluated not only in terms of dose distribution, but also in terms of dose-response characteristics of the given disease and the irradiated normal tissues. Until there is more reliable data, we should be careful when using these concepts to evaluate treatment plans.5

References 1 Maler A, Lutscher F. Cell-cycle times and the tumour control probability. http://mysite.science.uottawa.ca/flutsche/PUBLICATIONS/MalerLutscher2009.pdf. Accessed April 4, 2013. 2 Wiklund K, Toma-Dasu Iuliana, Lind BK. The influence of dose heterogeneity on tumour control probability in fractionated radiation therapy. Phys. Med. Biol. 2011;56(23):7585 7600. doi:10.1088/0031-9155/56/23/016. 3 Overview of Radiobiology. Radiation Oncology Blog Web site. http://radonc.wikidot.com/radiobiologyoverview. Updated September 7, 2009. Accessed April 7, 2013. 4 Deasy J. The Cartoon Guide to Radiation Oncology Modeling. [PowerPoint]. St. Louis, MO: Washington University School of Medicine. http://www2.isye.gatech.edu/ncinsf.orart.2002/pdf-files/deasy.primer.pdf 5 Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010.

Term #2: Active Breathing Control (ABC) Respiratory gating Large margins on gross tumor volume (GTV) within the chest are needed for adequate coverage throughout the respiratory cycle. These large margins can result in an increased risk of long-term side effects. Additionally, irregular breathing during computed tomography (CT) imaging or treatment is not desirable. The goal of simulation is to determine the best reproducible treatment position so the target can be localized and treated during every treatment. Several methods account for respiratory motion, such as active breath control or coordination (ABC), real-time tumor tracking systems, respiratory gating systems, the voluntary deep inspiration breath-hold (DIBH) technique, and abdominal pressure.1 The Active Breathing Control (ABC) concept was developed by Doctor John Wong at William Beaumont Hospital in 1997. The patient performs short, repeated breath holds so that the tumor can be treated in the same position starting from the CT simulation and throughout the treatment delivery. I understand it to be a sort of active immobilization. During an ABC procedure, a device is used to make the same breath-holding level for each session. The ABC contains a turbine spirometer that measures airflow and displays the respiratory curve on a computer. The system is customized to every patient or procedure, with variable threshold levels and breath hold durations possible.

Source: http://www.touchbriefings.com/pdf/1950/Elekta_tech_HIRES.pdf

The patient is always in control of the BH with the patient control switch. This switch must be pressed to start the ABC procedure and will automatically open a balloon valve if released so the patient can breathe freely.2 Its important to mention that breath-hold methods, such as ABC or DIBH, might be less practical in elderly patients or those with pulmonary dysfunctions.1 Respiratory gating is used at my facility to account for respiratory motion. A box is

placed on the patient and moves during the patient's respiratory cycle. The gating system uses a camera to track respiratory markers located on this box. Patients usually follow a recording breathing instructions to breathe in and breathe out. As the box's markers are analyzed, the radiation beam is turned on and off at a specific breathing phase to more accurately treat the target.3 Check out the following videos for additional information: Respiratory Gating System Radiotherapy: http://www.youtube.com/watch?v=tqSLxTd5r6c What is respiratory gating?: http://www.youtube.com/watch?v=cKOi41KSGCs Respiratory Gating: http://vimeo.com/59002541 Powerful tool for breast cancer: http://www.youtube.com/watch?v=YQTss_JQa6o This presentation provides useful information on managing respiratory motion: http://www.aapm.org/meetings/03SS/Presentations/Wong.pdf

References 1 Elekta. Management of Respiratory Motion? Do Hold Your Breath. TouchOncology.com Web Site. http://www.touchbriefings.com/pdf/1950/Elekta_tech_HIRES.pdf. Published 2006. Accessed April 7, 2013. 2 Gagel B, Demirel C, Kientopf A, et al. Active breathing control (ABC): Determination and reduction of breathing-induced organ motion in the chest. Int J Radiat Oncol Biol Phys. 2007;67(3):742-249. doi:10.1016/j.ijrobp.2006.09.052 3 Wong J. Methods to manage respiratory movement in radiation treatment. Talk presented at: 2003 AAPM Summer School; June 22-26, 2003. Colorado Springs, CO. http://www.aapm.org/meetings/03SS/Presentations/Wong.pdf. Accessed April 7, 2013.