NEW ADVANCED

IN RADIOTHERAPY

FIELDA DJUITA
DEPARTEMENT OF RADIOTHERAPY
“DHARMAIS” CANCER CENTER HOSPITAL
Jakarta, 11 November 2009
 CURRICULUM VITAE
Fielda Djuita
1977 : Medical doctor, University of Indonesia
1989 : Spesialis Radiologi, University of Indonesia
1990 : Sub Spesialis Radioterapi, University of Indonesia
1993 : Training Course in Treatment Planning System of Brachytherapy in Beijing
1997 : Fellowship in Radiology Imaging, Royal Perth Hospital – Australia
2002 : Study in Technique Radiation in Sentinel Node Procedure of Breast Cancer
in Academie Ziekenhuis Groningen.
2004 : Fellowship in Radiation Oncology in Toranomon Hospital, Tokyo - Japan
2005 : Training Radiotherapy at Sussex Country Hospital – Brighton and
St.Thomas Hospital – London, UK
2005 : International Gynecologic Cancer Society Course in Kyoto-Japan
2005 : European Society Therapeutic and Oncology.
2006 : American Society of Therapeutic Radiation Oncology, Philadelphia. America.
2007 : From 2D to 3 D Teaching Courses, St Petersburs , Rusia
2008 : IMRT Technique , Milan, Italia.

2
The aim of radiotherapy is to kill tumor
cells and spare normal tissues

• In external beam and brachytherapy one

inevitably delivers some dose to normal tissue
Brachytherapy sources
Beam 2
Beam 1 Beam 3

patient
tumor
 Basic” Radiotherapy Department
• 1 Teletherapy Unit (Co-60 or single
energy Linac with no MLC, portal
imaging or networking)
• Orthovoltage unit
• 1 Brachytherapy afterloader (HDR
or 2 LDR with full range of
applicators)
• 1 Simulator (or CT Simulator or
access to CT) Machine
• Computerized Treatment Planning
System
• QA and RP physics equipment
• Film processing equipment
• Patient immobilization devices and
mould room equipment
• 1 machine/ 500 patients IAEA Pub 1296
 Recommended number of staff
Radiation Oncologist chief
Radiation Oncology Staff
Medical Physicist
Dosimetrist or Physics assistant
Physics Technologist (Mould
rm)
Supervisor Rad Therapy Tech
Rad Therapy Staff
Staff simulation
Brachytherapy staff
Nurse
1 per program
1 additional per 200-250 pts treated
annually
1 per 400 patients treated annually
1 per 300 patients treated annually
1 per 600 patients treated annually
1 per center
2 per MV unit up 25 or 4 per MV up to 50 pts a
day treated
1 per 500 patients simulated annually
As needed
1 per center up to 300 patients
IAEA Pub 1296
 CANCER PATIENT : RT MACHINE
IN INDONESIA

RATIO NEED FOR RT

WHAT IS NEW
ADVANCED ?

HOW FAR
ADVANCED?
 WHAT DO WE REALLY NEED…?

• WHY DO WE NEED
WHO DOES
NEW ADVANCED NEED IT ?
TECHNOLOGIES ?
 Non-imaging features
Cross Hair stability with collimator,
gantry and couch rotation:
Mount a metallic pointer on table top
and observe its position relative to the
cross-hair on the fluoro monitor as the
collimator rotates. Repeat for gantry
and couch rotation. This should be
performed using both focal spot.

Laser Alignment

13 13
 Non-imaging features
Collimator , Gantry and Couch
Rotation and Isocenter Accuracy
Couch vertical, longitudinal and lateral
motions
Radiation Oncology
Radiation Oncology is a
quickly evolving field. A
little more than 10 years ago
2D was still common. Image
guidance was limited to a set
of port films or portal
images.
 Path Towards More Precise
Radiation Therapy
Industry Goal: Precisely Deliver Radiation to Tumors;
Avoid Healthy Tissue & Structure

Intensity Image Dose

Modulated Guided Escalation / Adaptive
Radiation Radiation Hypo- Radiation
Therapy Therapy fractionation Therapy
(IMRT) (IGRT)

•• Varies
Varies the
the intensity
intensity • IMRT requires • Reduces the number • Maximum precision
of the radiation
of the radiation imaging for precise of fractions and enabled by daily CT
targeting delivers larger doses imaging
•• Conforms
Conforms radiation
radiation of radiation per
to the shape
to the shape ofof the
the • Image guidance fraction • Treatment plan
tumor
tumor repositions patient adjusted to changes
for tumor • To date, used to treat in patient anatomy
•• Does
Does not
not account
account only a limited
for changes
for changes in
in movement and radiation actually
number of tumor delivered
anatomy
anatomy • Limited by the types
quality and • Personalized
frequency of images • Includes treatments designed
available Radiosurgery to optimize outcomes
External Beam Therapy’s Evolution

TomoTherapy evolved from CT scanners (newer style slip ring gantries).

C-Arms evolved from classic type diagnostic X-Ray machine designs.
TomoTherapy is the new paradigm IG-IMRT.
 C-Arm’s 40 Year Evolution

Clinac 4 Clinac 6-100 & 600c Clinac 1800c Clinac 2300 series
(1969) (1970’s - 90’s) (1980’s – 1990’s) (1990’s - 2000’s)

“Modern”
 RTOG Plan Comparison

Structure RTOG H-0022 Goal IMRT Plan Tomo Plan

Brainstem < 54 Gy Max 56.97 Gy Max 50 Gy

Spinal Cord < 45 Gy Max 47 Gy Max 15 Gy (!)

Mandible < 70 Gy Achieved Achieved

Unspecified 100% Vol • 110%

Achieved Achieved
tissue PTV66
Mean Dose < 26
Right Gy, or 60% Vol < 30 Gy 74% Vol < 30 Gy
Parotid
•50% Vol < 30 Gy
Mean Dose < 26
Left Parotid Gy, or •50% Vol < Only 1% Vol < 30 Gy 68% Vol < 30 Gy
30 Gy
 5 – Esophagus (case1)

HOT SPOTs

Isodose distributions for Tomotherapy, IMRT, and 3DCRT plans

CHEN et al. Helical Tomotherapy For Radiotherapy In Esophageal Cancer:
A Preferred Plan With Better Conformal Target Coverage And More Homogeneous Dose Distribution.
Medical Dosimetry, Vol. 32, No. 3, pp. 166-171, 2007
Step and shoot IMRT
7 – Lung (case1MPM) Tomotherapy

Higher Lower
Dose Dose
Regions Regions

STERZING et al.
Evaluating Target Coverage And
Normal Tissue Sparing In The Adjuvant
Radiotherapy
Of Malignant Pleural Mesothelioma:
Helical Tomotherapy Compared
With Step-and-shoot IMRT.
Radiotherapy and Oncology 86 (2008) 251–257
 Average Treatment Times
Treatments with Imaging:

• Site Time in Room Treatment Time (beam on) CT Time Target Length
• Esophagus 17 min 4 min 35 sec 2min 17 sec 13.8 cm
• Chest 21 min 6 min 29 sec 1min 41 sec 19.6 cm
• Head and Neck 13 min 4 min 13 sec 1min 12.7 cm
• Head and Neck 19 min 4 min 36 sec 4 min 37 sec 13.8 cm
• Chest 22 min 4 min 47 sec 2 min 17 sec 14.2 cm
• Head and Neck 17 min 4 min 50 sec 1 min 23 sec 14.3 cm
• Rectum 15 min 4 min 32 sec 1 min 42 sec 13.7 cm
• Liver 17 min 7 min 26 sec 1 min 47 sec 22.3 cm
• Bladder 15 min 4 min 18 sec 1 min 47 sec 12.8 cm

Treatments without Imaging:

• Head and Neck 13 min 5 min 11 sec 0 16.1 cm

• Head and Neck 12 min 6 min 5 sec 0 18.3 cm
• Head and Neck 10 min 6 min 0 18.2 cm

Courtesy of Southeast Regional Cancer Center

Tallahassee, FL
 Helical or TomoDirect?

• 50.4 Gy • 50 Gy
• 1.8 Gy/fx • 2.0 Gy/fx
radiation time: 12.5 min • 5 Beams
Case from University of Heidelberg,
Department of Radiation Oncology
• radiation time: 3.3 min
TomoTherapy Planning Study
 Quality Depends on Number of Beams

mm mm mm
1 Beam 5 Beams 11 Beams
17 Beams 25 Beams 51 Beams

mm mm mm
 COMPARISON DOSE DISTRIBUTION
BETWEEN TWO MODALITY

RapidArc Delivery TomoTherapy Comparison

Extreme Lack of Homogeneity High degree of homogeneity

But reported 2 minute beam on time and rectal avoidance
(Modulation takes time) 3.6 minutes beam on time
 THE CHOICE IS DEPENT OF OUR NEED
Ability to trade speed for quality

Field width 5 cm Field width 2.5 cm

Mod. Factor 1.2 Mod. Factor 2.4
More
conformal
target dose
Better cord
sparing

Treat time 2.1 mins Treat time 6.4 mins

More
uniform
nodal dose
 SPINE PLAN COMPARISON BETWEEN …..

CyberKnife
TomoTherapy
80% isodose
95% volume
= 16 Gy
= 20 Gy

65 minute 40 minute
beam time plus delivery time
80 direction
changes plus
collimator
change
 Repeat 4D cone beam CT

Shows respiration, tumor shrinkage and baseline position variation, J.J. Sonke
 Planning Technique Comparison
Mean Relative Reduction Versus Standard 3D

• All plans based on 63.0 Gy in 35 fractions

• 3D conformal plan based on CTV from free-breathing CT scan + 0.5 cm (setup) +
respiratory motion (maximum of 1.0 cm for motion)
• Mean tumor respiratory motion (SI) = 0.7 cm (range: 0.3-1.3 cm)
Harsolia et al. Int J Radiat Oncol Biol Phys 63S:A50; 2005
 Image volume of Cone-Beam

Electronic Portal
Coordinator or ABC Respiration
BREAST CANCER - ABC

Free Breathing Scan

Deep Inspiration Scan

Tumor Bed
Tumor Bed

Heart Heart
Border Border
Normal Respiration Deep Inspiration
 TRANSVERSE VIEW BETWEEN
NORMAL INSPIRATION & DEEP INSPIRATION
115%
Wedges IMRT
110%
105%
100%
95%
90%
ELECTRONIC PORTAL
IMAGING

MEDIAL FIELD
Sequential Images
( 4weeks)
 9 beam IMRT (72 segments)
Prostate 79.2 Gy to Prostate + SV

IMRT - Solid
VMAT - Dashed

Femoral
PTV
Volume

Rectum
Normal

Bladder

Dose (cGy)
 Prostate
IMRT 80 VMAT
73
60
50
40
30
20
10
5 Gy

717 MU, 12 minutes 501 MU, 2 minutes

 Hypofractionated Lung
8 Beam, 8 Seg IMRT VMAT

60
55
50
45
35
25
15
5
Gy

2200 MU, 14 minutes 2020 MU, 6.5 minutes

 Spine SRS
10 Beam, 45 Seg IMRT 2 arc VMAT

22
19
16
13
10
7
5
Gy

10998 MU 7482 MU
 VMAT vs. 7 beam IMRT
Head/Neck (80 segments)

IMRT 75 VMAT
70
66
56
45
35
25
15
10
Gy

925 MU 325 MU
TREATMENT PLANNING WITH BIOLOGIC FUNCTION
 CONCLUSION
• ADVANCED TECHNOLOGIES: MOVING TARGET
• “OLD” DOSE/VOLUME GUIDELINES:VALID IN IMRT ERA ?
• IMRT MOVES DOSE AROUND, NOT MAGIC ! ! !
• NEW APPROACHES ARE USUALLY COMPLEX
• OPPORTUNITIES FOR ERROR / INJURY
• THINK ABOUT BIOLOGIC FUNCTION
• CHALLENGING/ EXCITING TIMES
• LOCAL FAILURE: COMPLICATION
 CONCLUSION
• COMPARISON RATIO BETWEEN PATIENT: RT
MACHINE IS HIGH
• FOR MEDICAL SERVICES IN INDONESIA WE NEED
A LOT OF MACHINE WITH MEDIOCARE
TECHNOLOGIES
• FOR CANCER CENTRE OR EDUCATION WE NEED
HIGH TECHNOLOGY MACHINE
Everyone thinks of
changing the world,
but no one thinks of
changing himself on
her self.
(Leo Tolstoy, The Kingdom of God is
within you)
merci