TOMO的技術特征和臨床價值-黃歲平

螺旋斷層放療Tomo

的技術特征和臨床價值黃歲平博士Dec62013螺旋斷層放療的技術特征與臨床價值DrMeshMeta：全球第一位使用TOMO的放療科主任WhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,AvoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapy++FastBinaryMLC(MultileafCollimator)ContinuousGantryRotationSimultaneousCouchMovement高調制TheKeyTechnologyofHelicalTomoTherapy多角度長覆蓋

Modulatedbeamsthroughoutone360degreerotation.Theprocesscontinuesforallrotations…BinaryMLCIntensitylevelsinonemodulatedbeamOnebeamletwithinthebeamModulatedBeamDeliveryHelicallyDeliveredDoseDistributionsWhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,AvoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyImageGuidanceviaImageFusionColoredsegments=MVCTGreysegments=planningCTRepositioningShiftsAfterImage-GuidanceonTomotherapyAStatisticalAnalysisofH&N,Lung,andProstateTreatmentSitesLeahKamin,UniversityofWisconsinTable1:Mean±standarddeviationsofrepositioningshifts

3DVectorTreatmentSiteLateral(mm)Longitudinal(mm)Vertical(mm)Length(mm)Roll(degrees)*H&NandBrain(n=643)0.383±3.09-0.124±2.600.791±3.014.43±2.540.250±1.54Lung(n=1414)0.629±5.77-0.971±7.850.396±8.0110.6±6.990.177±1.22Prostate(n=1274)0.243±4.934.75±8.432.30±5.8910.8±6.460.282±.707*H&Nandbrain(n=579),lung(n=1179),prostate(n=980)Table2:Percentfrequency(%)of3Dvectorlengthoffsets

TreatmentSite≥20mm≥10mm≥5mm≥3mm≥2mm≥1mmH&NandBrain(n=643)0.1561.5636.772.386.294.9Lung(n=1414)5.4548.984.493.495.596.5Prostate(n=1274)7.3848.185.8792.795.496.3Table3:Percentfrequency(%)ofmagnitudesofrotational(roll)offsetsTreatmentSite≥4°≥3°≥2°≥1°H&NandBrain(n=579)3.978.1218.130.9Lung(n=1179)1.784.241226.8Prostate(n=980)0.1020.3061.8418.9WhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,AvoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyCraniospinalAxisTreatmentPatienttreatedsupinewithnofieldjunctionsConventionalLinacCourtesyofWillis-KnightonCancerCenterShreveport,LAHelicalTomoTherapyPatienttreatedpronewithtwofieldjunctions“Magna-FieldRadiotherapy”WholeAbdomenCityofHope:TMIPelvic/paraaorticnodalWhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,AvoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyCourtesyMineshMehta&EmilieeSoisson,UniversityofWisconsinMultipleTargetsinSingleSetupPTVHippocampusSolidHomogeneousDashedGradientMultipleTargetsinSingleSetupMultipleBoneMetsMultiplePrescriptionsHeadandNeckMultiplePrescriptionsProstateandNodesWhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,avoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyAvoidingthehippocampusHelicalDeliveryBinaryMLC/6.25mmleavesConformityindex:1.35Dosegradient:3.59%/mm7-fieldIMRT3mmMLCleavesConformityindex:1.82Dosegradient::2.96%/mmCityofHopeNationalMedicalCenterAvoidingthechiasm/pitglandAvoidinganything,really!WhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,avoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyNSCLC:OvercomingAcceleratedRepopulationFowlerJF,ChappellR,IJROBP,2000;MehtaMP,Fowler,IJROBP2001;BelaniC,MehtaM,JCO,2005;Adkison,Mehta:TCRT,20082000:EvidenceforacceleratedrepopulationinNSCLC2001:TDFmethodtoovercomeresistance2005:EvidenceforbenefitofacceleratedRT2008:AcceleratedHTwithlowtoxicities,?survivalimprovementBINDose/FXDoseBEDN12.28576022.5363.257032.7769.258043759053.2280.5100LowerthanExpectedToxicities;SurvivalImproved?Grade2Pneumonitis13%Grade2Esophagitis15%Grade3Pneumonitis0%Grade3Esophagitis0%2yearSurvival47%MedianSurvival18monthsNoChemo43%,Neoadjuvant24%,Adjuvant33%AsComparedto21.5%ExpectedTwoYearSurvivalStereotacticBodyRadiotherapywith4DIM-IGRTHodgeW,MehtaMP.ActaOncol.2006;45:890-6N=23,inpress88%4YLC78%4YCSSProstate:Exploitingα/β(FractionalSensitivity)FowlerJF,RitterM,IJROBP,20012000:Rectalballoonimmobilizationtechnique2001:DataAnalysisforlowprostateα/β

2002:ProstateHypofxPO1protocol2004:ProstateHypofxmulti-institutionalRO12009:InitialdataanalysisBINDose/FXFxsDoseBED312.942264.6812823.631658.0812834.31251.6126BINNF/U(mo)2YPFSBED10110326.3>95%84210921>95%7931009.3>95%74Prostate:KeepingToxicitiesLowTomotherapySRS:AVMasaModel

Rt.OccipitalAVMVol=5.01cc2+hoursplanningtime11isocenters4collimatorchanges3+hoursonthetablePinnacle-ThickSolidMatch-DashedOriginalPlanMatchSoissonE,TomeW,MehtaMP,UWisconsinTomo’sChoiceOriginalPlanChoiceOriginalPlanMatchLinacMatchChoiceVolRx4.76cc4.75cc4.77ccTC95%95%95%PIV9.8cc9.5cc7.44cc12GyVol22.2cc27.6cc23.3ccPITV1.961.891.49CN2.172.101.64CGI6048.357TimeHours20.5min18.2minVolRx=VolumeoftargetreceivingprescriptionTC=TargetCoverageVolRx/TVHI=MaxDose/RxPITV=PIV/TVCI=VolRx/PIVCN=1/(CIxTC)WhatisTomoReallyGoodAt?DailyImageGuidanceVerylargefieldset-upsCraniospinal,wholeabdomen,TMIMultiplelesions/prescriptionsBrain,bone,othersH/NmultipleprescriptionsComplicatedgeometriesandset-upsMesothelioma,retreatments,avoidanceExploitingradiobiologyAlteredfractionation,SBRT,TheragnosticsAdaptiveradiotherapyAdaptiveRadiotherapyWeek1Week3CalculatedailydosesModifyoriginalcontoursMaphotdoselevelsContourhotspotandmakeitaconstraintAdaptiveRadiotherapyPre-RTKvCT;intra-RTMvCTSCLCafter18Gy++DiscreteBeamAnglesContinuousCouchMotion=MovingCouchFastBinaryMLC(MultileafCollimator)TomoDirectWBRTMultiplelesionsEfficient,IMRT,accuratesimplefieldse.g.TangentsTomoDirect+Tomo:TheBreastSolutionDynamicJawSavesTime:WholeAbdominalRTtreatmenttime