Introduction and overview of

TRUE BEAM
initial experience in Humanitas
FILIPPO ALONGI M.D.
Istituto Clinico Humanitas
Radiotherapy and Radiosurgery Dept
Dept..
Humanitas cancer center
Radiotherapy Department

CT SIMULATOR

TRUEBEAM
DHX- OBI, CBCT

Technologies:

•4 linear accelerators (Varian) – OBI and Cone Beam CT

•1CT simulator (Philips, Big Bore, 16 slice)
•5 Treatment planning systems (4 Eclipse+1Ergo)
•4D system for gated respiratory motion
•Tools for radiosurgery and SBRT
 Radiotherapy@Humanitas in 2010

Other
GI
GU

Brain
Lung

Gyn

Sarcomas

H&N

Breast
Metastasis

Patients treated in the last year in RT

 What is our strategy ?

Multimodality IGRT and

images adaptive RT
CT/PET/MRI

Precision
Accuracy
Efficiency

IMRT and Radiosurgery

VMAT and SBRT
 True Beam
Beam:: Technical features

• Greater precision (isocentre <0.3 mm) Gating device

• Online fluoroscopy (in

in--treatment
tumour visualization
visualization))
• Synchronization of tumour irradiation
with breathing (tumor tracking
tracking))
• Shorter treaments (< 2 minutes)
minutes) MV imager
• High Dose Intensity
• Digital autocontrol of the machine
KV imager
parameters

• Realized in Silicon Valley (first in Italy,

only two other machines in Europe
Europe))
 Robotic controle of Positioning Unit (PU) and IsoCal

kV-Source Gantry Side

Arm
• Three robotic
arms
kV-Detector
• Responsible for Arm
imaging and
detector units
kV-Source

MV-Detector
Arm
kV-Detector
Hand holder

MV-Detector
Hand holder

Treatment iso
 Creates an ideal image guidance
machine by alignment of the imaging
system to isocenter
 ‘True’ isocenter is a single point
which coincides with the kV/MV
kV imaging iso rotation centers and where the center
of the imagers project
Specification for imager to treatment
MV imaging iso

isocenter is 0.5mm
 TRUE BEAM
Some appealing features - beam

• RapidArc IMRT with FFF (10X: 24 Gy/min)

• Automated Simultaneous, synchronized control points

for all axes
(MLC, MV beam, gantry, table, collimator, 3rd party, kV
beam)

• Collimator and couch rotation during beam-on

• Jaw tracking for IMRT and RapidArc

• Table tracking, MLC tracking

• Connected Multiple isocenter plans (e.g., SRS, long

fields, imaging fields)

• Preventive Collision detection during machine motion

(safety)

• Isocal: automatic alignement of imaging and Tx

isocentres

Courtesy of L. Cozzi Not all features available at first release

Flattering filter vs FF free

D1pre >> D2pre

D1 D1 = D2 D2
 TRUE BEAM: Beams profiles

6FFF 6X

10FFF 10X
 TRUE BEAM
Some appealing features - imaging

• Combined (kV-MV) single and continuous

• Synchronous acquisition using both

modalities

• Combined (kV during MV) single and

continuous

• Combined kV-MV single and continuous

synchronised with gating

• kV 4D CBCT

Courtesy of L. Cozzi Not all features available at first release

TrueBeam Imaging Examples
 TRUE BEAM
Some appealing features - imaging

•Observe motions before AND during

treatment

• ‘’Fluoroscopy-based’’ respiratory gated

RapidArc

• ‘’Fluoroscopy based’’ motion detection

for anatomical target tracking

Courtesy of L. Cozzi Not all features available at first release

 TrueBeam Imaging Examples

Fluoro_during_RA_LUNG.wmv

Courtesy of Zurig
 TRUE BEAM clincical potential advantages

•Higher doses to the

GREATER PRECISION tumor
in: (improves local control)

•Increased possibility to
Delivery high doses
use non conventional
fractionation (decreases
Image guidance toxicity with SBRT)

•New clincal application

Flattering Filter Free
•New Radiobiology
(FFF) implications
 TrueBeam@Humanitas

Installation 10/7-15/8/2010
Acceptance tests 16/8-20/8/2010
Commissioning 23/8-19/9/2010
1st patient 20/9/2010
Total patients 123 @31/12/10
 TRUE BEAM initial clinical experience
123 patients(68 with FFF) 98/123 pts completed the treatment.

Brain and CNS= 8pts

H&N= 4pts

Lung= 73pts(49pts FFF)

•20 pts >4 fr.(20Gy-30)

•53 pts ≤4 fr.(32-48Gy)

Abdomen =25pts

-Liver 13pts (9FFF) (75 Gy/3fr)

-Ln 7pts (45 Gy/6 fr.) (3FFF)

-Other 5pts (pancreas=3, adrenal glands=2)

Other sites =13pts (7FFF)

 TRUE BEAM for new Clinical Applications

Greater precision (isocentre <0.3 mm)

Online fluoroscopy (in-treatment tumour

Precision visualization
Accuracy
Selectivity Synchronization of tumour irradiation
with breathing (tumor tracking)
Efficiency

High Dose Intensity: radiobiology effect

and research

Flattering Filter Free beams

Ablative
Radiosurgery and SBRT

• Early lung tumors

• Primitive and metastatic abdomen and pelvic
TRUE BEAM Clinical applications

First patients with 10FFF

 TRUE BEAM initial clinical experience
with FFF beam
68 FFF treatments Acute toxicities: no ≥ G2

49 SBRT for lung lesions:

•Doses: 32-48 Gy in 4 fract.

•Toxicity:1 case of G1 esophagitis

9 SBRT liver lesions:

•Doses: 75 Gy in 3 fract.
•Toxicity:1 case of G1 nausea/vomit
 TRUE BEAM initial clinical experience
with FFF beam
68 FFF treatments Acute toxicities: no ≥ G2

3 SBRT for abdominal lymph nodes:

•Doses: 45 Gy in 6 fract.
•Toxicity: none

7 other sites in the body:

•Doses: various.
•Toxicity: none
 True Beam potential applications
applications::
SBRT LUNG

2010 TRUE BEAM

RESULTS
Flattering Filter Free beams:
•The survival rate for SBRT is potentially
comparable to that for surgery. Higher doses delivered more
precisiously

Vassiliev ON et al. Stereotactic

radiotherapy for lung cancer using a
flattening filter free Clinac. J Appl Clin Med
Phys. 2009 Jan 27;10(1):2880.
SBRT in lung: 12Gyx4;10FFF;DR 2400.

4D CT
2 isocentres
2 full arcs
Jaws tracking
MU: 3014+3606
BOT:75+91s

Heart: mean dose = 2.6

Gy
Lung: mean dose = 7.5
Gy (left) 5.7 Gy (right)
Spinal Cord: max dose =
13.0 Gy
SBRT in lung: 6Gyx6;10FFF;DR 2400.

1 isocentres
2 partial arcs
Jaws tracking
MU: 2212
BOT: 2x 32 s

Heart: mean dose = 3 Gy

Lung: mean dose = 2 Gy
(left) 8 Gy (right)
V5Gy = 40%
V20Gy = 8%
Esophagus: V33Gy ~ 0%
 SBRT
SBRT in
IN abdominal
ABDOMINAL TARGETS
TARGETS

ACCEPTED 2011

Stereotactic body radiation therapy for abdominal targets using volumetric intensity
modulated arc therapy with RapidArc: feasibility and clinical preliminary results

Marta Scorsetti,1 Mario Bignardi M,1 Filippo Alongi,1 Antonella Fogliata c,2 Pietro Mancosu 1 Piera
Navarria,1 Simona Castiglioni,1 Sara Pentimalli,1 Angelo Tozzi MD,1 Luca Cozzi,2

1 IRCCS Istituto Clinico Humanitas, Rozzano (Milano), Italy

2 Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
 True Beam potential applications
applications::
SBRT LIVER

Liver metastasis treatment in ICH

Radioablation

RAPID ARC 75 Gy in 3 fractions

TRUE BEAM Better precision… more ablative doses?

 Humanitas LIVER SBRT protocol

Organ at risk Dose constraints Other conditions

(for 3 fractions)

Normal liver > 700 cc at < 15 Gy Volume > 1000 cc

(total liver - CTV)

Spinal cord < 18 Gy -

Kidneys V15 Gy < 35%

Heart < 30 Gy Esclusion criteria

CTV at < 8mm

Stomach, duodenum, small < 21 Gy Esclusion criteria

bowel, principal biliar ducts (Dmax) CTV at < 8 mm
 Humanitas LIVER SBRT protocol

Dose/fraction Number Median dose

fractions

Standard dose 25Gy 3 75 Gy

Dose reduction 10% 22.5 Gy 3 67.5 Gy

Dose reduction 20% 20. 63 Gy 3 61.89 Gy

Dose reduction 30% 18.75 Gy 3 56.25 Gy

Humanitas LIVER SBRT protocol
 CT simulation & CB CT

Basal
Arterial
phase
Venous
phase
Late Venous
phase
CB_CT
Day I CB_CT
Day III
Humanitas protocol
 SBRT with Rapid Arc

CT pre Simulation CT

F, 62y, liver met, 75 Gy/3 fr

CT post
 FFF vs FF for liver metastases

• 13 liver lesion patients

• 25 Gy for 3 fractions optimized on PTV For target best solution
• Variable PTV volumes (20 to 300cc) depends on lesion
• 4 plans/patient: FFF with collimator at 10° and 45° volume
FF with collimator at 10° and 45°

Parameters:

• PTV Conformity Index FF

 Body _ V95% 
CI   
 PTV _ V95% 

• HT mean dose

•CTV mean dose FFF

better sparing on HT
 FFF vs FF for liver metastases

FF coll 45°

20-70cc 71-110cc 111-200cc

FFF coll 45°

20-70cc 71-110cc 111-200cc

Reggiori ESTRO 2011 submitted

SBRT liver with TB: 25Gy x 3; 6FFF; DR 1200.

1 isocentre, 1 arc MU: 5642

Jaw tracking BOT: 137 s

Spinal cord max dose = 17.3 Gy

Right kidney mean dose = 3.9 Gy
Liver mean dose = 15.7 Gy
Stomach mean dose = 19.3 Gy
 SBRT liver: 25Gy x 3; 10FFF; DR 2400.

1 isocentre, 3 arcs
Jaw tracking
PTV1&PTV2: V95%=99.5%
Spinal cord: Max dose=17.3 Gy
Stomach: Max=21.0Gy, Mean=9.5 Gy MU:3216+3527+563
Liver: Mean=15.5 Gy, D15Gyfree=712cc BOT: 80+82+14s
Prospective Phase II multicentric study of SBRT
for liver metastases

From December 2009 to December 2010

24 patients (21 with Rapid arc, 3 FFF with TB)
TB

 16 total dose, 8 reduction of dose to 30%

 Only 1 acute toxicity gr2 (vomiting)
 Increase of γGT in 5 patients without altered hepatic function
 Median FU: 8 months
7 CR - 4 PR - 5 SD - 5 PD (local, out of treatment volume)
 SBRT abdominal lymph nodes
Abdomen:LN mts

2009

2010

DOSE: 45 Gy/ 6 Fr
SBRT: 3.5Gyx10;6FFF;DR 1200.

Rectum mean dose = 9.9 Gy

Femoral heads mean dose = 1.6 Gy

1 isoc, 1 arcs
Jaws tracking
MU: 1065
BOT: 66 s
SBRT: 7.5Gyx6;10FFF;DR 2400.

1 isoc, 1 arcs
Jaws tracking
MU: 1697
BOT: 60 s

Kidneys mean dose = 1.5 Gy

Spine: max dose = 7.5 Gy
 Other Clinical Applications
Other special techniques:
• Total Marrow Irradiation (TMI)
• Partial Breast Irradiation
• Vertebral re-treatments
• Cervico-facial district re-treatments
• Whole brain irradiation with
integrated boost on cerebral lesions.
Intensity Modulated Radio Therapy
(IMRT) and Image Guidance (IGRT):
• Locally advanced lung tumour
• Pleuric mesothelioma
• Breast irradiation with Simultaneous
Integrated Boost
• Cervico-facial district neoplasiae
• Esophagus tumours
• Pre operatory rectum cancer
• Radical and post-operatory prostate
cancer
• Vertebral metastasis with spinal cord
saving
Nasopharynx re-treatment: 6Gy x 5; 10FFF; DR 2400.

MRI

1 iso, 2 arcs
Jaws
tracking
MU:
925+1105

PET BOT:60+60s
Nasopharynx re-treatment: clinical
response

Pre-RT

Pre-RT After 45
days
SBRT brain: 6Gy x 4; 6FFF; DR 1200.

1 isoc, 1 arcs, 4 lesions

Jaws tracking
MU: 1523
BOT: 68.4 s

Optical nerves max dose = 10.5 Gy

Brainstem mean dose = 7.5 Gy
Total Marrow Lymph
Lymph--node Irradiation - 1

First patient treated

A second protocol is in assessment: TMLI in lymphoma

First patient treated on October 26:
TMLI for Hodgkin lymphoma stage IVB.
Marrow stem cell transplant from his son.
Low intensity conditioning + ciclophosphamide

PTV TML: 2.2 Gy. PTV boost: 2 Gy

Delivery on TrueBeam with 10 arcs and 5 isocentres.
10 MV photons
Lower legs with AP-PA fields.
Both plans are summed in Eclipse,
AP-PA used as base dose plan for RA

Pre-treatment QA done with MatriXX and PortalImaging

Image guidance: CBCT at every isocentre
Total Marrow Lymph-
Lymph-node Irradiation - 2

Beam On Time = 12 minutes

Good healthy tissue

sparing

Prescribed 2.2 Gy in order to have 2

Gy on the whole target
Total Marrow Lymph-
Lymph-node Irradiation - 3

Good dose homogeneity

and good QA results

PTV: V2Gy=99.8%

HT: mean dose=1.2Gy

 Total Marrow Irradiation with TrueBeam

Phase II trial
Total marrow irradiation (TMI) using VMAT-Rapid Arc as part of
preparative regimen for allogeneic stem cell transplantation and
autologous stem cell transplantation

Primary objective and end-point: Age 18-65. 2x36 patients

Response Rate: CR and PR
Allogenic: Acute Myeloid Leukemia
100-d treatment related mortality
Autologous: Multiple Myeloma relapsed after
autologous stem cell transplantation

Secondary objective and end point: OS,
PFS, response rate, incidence of severe
toxicities (grade III/IV)
Allogenic regimen: 12 Gy TMI + Fludarabine,
Busilvex, ATG
Autologous regimen: 12 Gy TMI + Melphalan
100mg/m2

Pre-clinical phase:
In silico evaluation of planning
techniques and delivery accuracy
 TRUE BEAM: CONCLUSION

RAPID ARC SBRT with FFF

VMAT delivery delivery

IMPROVE
CLINICAL
OUTCOME

CONE BEAM FLUOROSCOPY

PATIENT BASED APPROACH

TRUE BEAM TEAM: Thanks!!!
Thanks!!!