CONFORMAL

RADIOTHERAPY

Dr.S.Ashokkumar
Senior Medical Physicist
IMRT: how modulate the intensity?
 Compensator based IMRT
Compensator are used to modulated intensity.
Compensator must be constructed for each
gantry position employed and placed in beam
for each treatment.
MULTILEAF COLLIMATOR
Multiple Static Segment (MSS) Delivery
Sliding Window Delivery
 Conversion from
continuous to discrete intensity profiles

DMLC IMRT MSS IMRT

DMLC -Mathematical advantage
DMLC has more degrees of freedom,
hence an equal or better solution will
always be found
 FROM IMRT TO IMAT (Rapid arc)
Advantage of IMRT:

More conformal dose, better sparing of OAR

Several dose levels for PTV

 Disadvantage of IMRT:
more static beams,

more MU (machine dose)

more time for planning and for delivery

Larger volume of low dose in PTV planes

Higher peripheral dose far from PTV (proportional to

MUs)
 VMAT
Volumetric modulated arc therapy (VMAT) is a
novel radiation therapy technique that delivers
the radiation dose continuously as the treatment
machine rotates. This technique accurately shapes
the radiation dose to the tumour while minimizing
the dose to the organs surrounding the tumour.
 Field Setup - General arc properties

Insert a New Field:

Machine: has to be suitable

for RapidArc delivery

Energy: low energy or also high?

Dose Rate: the maximum allowed.

This permit the highest degree of
freedom in modulating through
dose rate and gantry speed
variation
 Manual arc definition I
Technique: ARC


Gantry: gantry start and stop positions.
 Limitations:
• maximum of 1000 degree per plan


Direction: CW or CCW


Collimator: the collimator angle shall be
different from 0°.
This will spread in the whole body,
during gantry rotation, the tongue and
groove effect and interleaf leakage.

Couch: can be different from 0°

NON COPLANARITY POSSIBLE!
The Optimizer functions
 Definition of the constraints (objectives):
 Upper objective: to minimize
 Lower objective: to maximize
 Resolution [mm]
 Priorities (max value 1000)
 Modifications possible during optimization
 End of optimization
 Results from the optimization phase:
 MLC shape for all 175 control points (about 2 degrees for a
whole arc)

 Dose rate and gantry speed for each control point:

 Max Dose Rate = 600 MU/min (or 1000)

 Max Gantry Speed = 4.8 °/sec

 At the end of the optimization the arc is deliverable

 Optimization results will be used to calculate dose

distribution
 Constraints for Treatment delivery
Gantry speed - Max. 65 secs per rotation [5.5 deg/sec]
Leaf speed - Max speed < 2.5cms/sec [0.5 cm/deg]
Dose rate - Max dose rate of the field
Dose / degree - Max 20 MU/deg SRS system
Maximum MU - 3000 MU, 6000MU for trilogy SRS
Efficiency - Gantry moves at max speed as much as
possible
Smoothness of delivery - Gantry speed variation
 Partial arcs: when and why
 Some cases that may benefit from partial arcs

 Cases where specific entries are better to be skip but avoidance

sectors are not the best usage: remember that the degrees of the avoidance
sectors are counted in the 1000 degrees available for the whole plan
 E.g. “Lateral targets”

Note: the isocentre

position must leave
space for gantry
rotation!
 Multiple isocentres: when and why

 Mostly long volumes need multiple isocentres

 Cranio-spinal irradiation
 Long lymphomas
 Any long target…


The different arcs must

have an overlapping
 overlap
region (“field” length).
 
The optimization will
account for the set
overlap.
 Non coplanar arcs: when and why

 Some cases may benefit from non coplanar arcs:

 Brain tumours where non coplanarity can geometrically avoid critical
structures
 Any other site where non coplanarity is geometrically beneficial
 Head & Neck

IMRT RA
 GTV & PTV

Rapid Arc

GTV
Rapid Arc
IMRT

Steepness of PTV DVH curve & D95 of Rapid Arc

were comparable with IMRT
 Left Parotid

Parotid Left

IMRT

Rapid Arc

Left Parotid IMRT Rapid Arc

Mean Dose 2733 2402
(cGy) (13.7% dose < IMRT)
 Spinal Cord

Spinal cord

IMRT

Rapid Arc

Oral Cavity IMRT Rapid Arc

Max Dose (cGy) 3891 3644
 Pelvis

IMRT RA

IMRT Rapid Arc

MU 1434 525
Fields / Arcs 7(14) 1 (360°arcs)
Treatment Time 12 min 1.3 min
70% Isodose Volume 4003.00 cc 3681.00 cc (8.7% vol < IMRT)
40% Isodose Volume 9033.00 cc 8229.00 cc (9.7% vol < IMRT)
Multiple Mets
 Rapid Arc benefits
Shorter treatment times
1.5 to 2 min. vs. 8 to 15 min.
Reduced patient motion during
treatment
Increased patient comfort
Increased patient throughput
– Larger proportion of therapist effort spent on
setup quality assurance
Reduced dose to normal tissue
Benefits of RapidArc
Benefits of RapidArc

MU Gain Time Gain

 Rapid Arc Flow Chart
Contouring

Auto Setup Field Setup

MLC Parameters Optimization Objectives

Control Points Leaf

motion MU/Deg & MU/min

Transition Fluence

AAA 3D Calculation

QA & Delivery
 CONCLUSION
Rapidarc is one format of rotational IMRT for dose
painting
Implementation of Rapidarc requires careful planning
testing & verification
Thoroughly testing and commissioning are necessary
prior to patient treatment.
QA is a critical step, always compare with static field
IMRT plan in the early phase
Rapidarc should be judged by its accuracy , safely
efficient, applicability, integration and adaptation
 SRS
Stereotactic Radiosurgery (SRS)
and stereotactic radiation therapy (SRT)
are advanced and modernized forms of
radiation therapy. They allow us to deliver
high dose radiation to a small focused
area.
 SBRT
Stereotactic radiosurgery (SRS) is a type
of radiotherapy. When it's performed on
the body rather than the brain, this
procedure is sometimes called stereotactic
body radiotherapy (SBRT) or stereotactic
ablative radiotherapy (SABR).
 TOMOTHERAPY

A type of therapy in which radiation is

aimed at a tumor from many different
directions. The patient lays on a table
and is moved through a donut-shaped
machine.
Delivery by two methods
Slice based tomothrerapy
Helical tomotherapy
 IMRT Interplay effect

Contouring (target, critical structures)

Intra-fraction organ motion
– Addressed by margins for 3D-CRT
– IMRT: there may be interplay between anatomy and MLC motion
Interplay between anatomy and MLC leaves: moving target
leads to differences between planned and delivered dose
distribution
Dose

Planned dose
Delivered dose

Position
 Motion Management
Intrafraction tumor motion remains a challenge
in the treatment of mobile targets
(eg.Lung,Liver).

To ensure CTV receives the prescribed dose

PTV must be large enough to account for the
respiratory motions

Excessive irradiation of normal tissue- limiting

factor for dose escalation
 Motion Management
Thoracic tumours move by more than 2 cm

The movement of lung lesions has been found

to be greatest in the lower lobes

Liver can move by more than 3cm

 Motion Management
Motion encompassed methods

– Tumor motion tracking and gating

– Breath hold method

Motion Management - Motion encompassed methods

Population-Based
Or
Internal Target Volume
Motion Management - Tracking and Gating
 RPM Gating
Camera in Treatment room
Marker Block

RPM workstation

Camera in CT room

Moving Phantom
 Prospective
• Images are Collected only on one phase of the
respiratory cycle

• CT data is acquired only in the threshold from

the RPM system

• CT acquisition on Free breathing or Breath

hold
Deep Inspiration Breath Hold
 Retrospective
• 4DCT acquisition

• CT data are acquired at all phases of respiration per

longitudinal coordinate.

• CT acquired images and the respiratory motion data

are transferred to the Workstation -which correlates
the respiratory phase information to each acquired
image.

• Images can be saved in Database based on their

respiratory phase.
Retrospective scan
4DCT Data
4D CT WORKING WINDOW
 Concept of ITV – ICRU 62
ITV: Clinical target volume
(CTV) plus an additional
margin to account for
geometric uncertainties due
to internal variations in
tumor position, size & shape