Three Three-Dimensional Conformal Dimensional Conformal - PowerPoint PPT Presentation

Three Three-Dimensional Conformal Dimensional Conformal Radiotherapy (3DCRT) Radiotherapy (3DCRT) Treatment planning for external beam Treatment planning for external beam Prof. Dr. Golam Abu Zakaria Prof. Dr. Golam Abu Zakaria Gummersbach Hospital Gummersbach Hospital Academic Teaching Hospital of the University of Cologne Academic Teaching Hospital of the University of Cologne Department of Medical Radiation Physics Department of Medical Radiation Physics 51643 Gummersbach, Germany 51643 Gummersbach, Germany E-Mail: GolamAbu.Zakaria@Klinikum Mail: GolamAbu.Zakaria@Klinikum-Oberberg.de Oberberg.de

Professionals involved in the treatment planning Professionals involved in the treatment planning process process (IAEA) (IAEA)

The radiotherapy chain The radiotherapy chain • • A characteristic feature of modern radiotherapy is a A characteristic feature of modern radiotherapy is a multi multi- -disciplinary disciplinary approach approach , consisting of and usage of many complex devices and procedures. , consisting of and usage of many complex devices and procedures. Clinical examination Treatment planning: Simulation and dose calculation Treatment planning: 3D Imaging Evaluation and assessment Dosimetric verification and checks Radiotherapy Therapeutic decision Localization of target volume and organs at risk Patient- positioning Aftercare, evaluation

The Radiotherapy Chain The Radiotherapy Chain example: example: Linear accelerator Computertomograph Image data Simulated and marked radiation fields Treatment planning system Therapy simulator Planned radiation fields

Radiotherapy treatment goal Radiotherapy treatment goal • The objective of radiotherapy is the destruction of local tumour The objective of radiotherapy is the destruction of local tumour without severe side effects without severe side effects • Removal of the tumour Removal of the tumour – (Local tumour control / Regional tumour control) – (Local tumour control / Regional tumour control) (Local tumour control / Regional tumour control) (Local tumour control / Regional tumour control) • Avoidance of treatment effects Avoidance of treatment effects – disfigurement disfigurement – loss of function loss of function – restriction of quality of life restriction of quality of life • Therapy optimization: maximum effect with minimal burden Therapy optimization: maximum effect with minimal burden

Tolerance doses in Gy (Emami et al). (Emami et al). Tolerance doses in Gy Organ Organ TD 5/5 TD TD TD 5/5 TD TD 5/5 TD TD 50/5 TD 50/5 TD TD 50/5 TD Radiation consequense Radiation consequense 5/5 5/5 5/5 50/5 50/5 50/5 Volume part Volume part 1/3 1/3 2/3 2/3 3/3 3/3 1/3 1/3 2/3 2/3 3/3 3/3 Arm nerve plexus Arm nerve plexus 62 62 61 61 60 60 77 77 76 76 75 75 Manifeste Plexopathie Manifeste Plexopathie Lens Lens 10 10 18 18 Katarakt Katarakt Bladder Bladder 80 80 65 65 85 85 80 80 Symptomatische Schrumpfblase Symptomatische Schrumpfblase Cauda equina Cauda equina no Volume effect no Volume effect 60 60 no Volume effect no Volume effect 75 75 Manifeste Neuropathie Manifeste Neuropathie Chiasma opticum Chiasma opticum no Volume effect no Volume effect 50 50 no Volume effect no Volume effect 65 65 Blindness Blindness 40 a Small intestine Small intestine 50 50 - 40 60 60 - - 55 55 Stenose, Perforation, Fistel Stenose, Perforation, Fistel Femurkopf (I+II) Femurkopf (I+II) - - 52 52 - - - 65 65 Bone necrosis Bone necrosis 100 cm 2 : 100 cm 2 : 100 cm : 100 cm : 10 cm 2 2 : 50 30 cm 2 : 60 10 cm 2 : 30 cm 2 : Skin Skin 10 cm : 50 30 cm : 60 10 cm : - - 30 cm : - - Nekrose, Ulzeration Nekrose, Ulzeration 55 55 70 70 Heart Heart 60 60 45 45 40 40 70 70 55 55 50 50 Perikarditis Perikarditis Brain Brain 60 60 50 50 45 45 75 75 65 65 60 60 Nekrose, Infarkt Nekrose, Infarkt Brainstem Brainstem 60 60 53 53 50 50 - - - 65 65 Nekrose, Infarkt Nekrose, Infarkt TMJ TMJ 65 65 60 60 60 60 77 77 72 72 72 72 Trismus Trismus Colon Colon 55 55 45 45 60 60 55 55 Stenose, Perforation, Fistel, Ulkus Stenose, Perforation, Fistel, Ulkus Larynx Larynx 79 79 a a 70 70 a 70 70 a 90 90 a 80 80 a 80 80 a Knorpelnekrose Knorpelnekrose 45 a 80 a Larynx Larynx - 45 45 45 - - - 80 Larynxödem Larynxödem Liver Liver 50 50 35 35 30 30 55 55 45 45 40 40 Liver failure Liver failure Lung Lung 45 45 30 30 17,5 17,5 65 65 40 40 24,5 24,5 Pneumonitis Pneumonitis Stomach Stomach 60 60 55 55 50 50 70 70 67 67 65 65 Ileus, Perforation Ileus, Perforation Middle Ear/Externa Ear Middle Ear/Externa Ear 30 30 30 30 30 30 a 40 40 40 40 40 40 a Akute seröse Otitis Akute seröse Otitis 55 a 65 a Middle Ear/Externa Ear Middle Ear/Externa Ear 55 55 55 55 55 65 65 65 65 65 Chronische seröse Otitis Chronische seröse Otitis Kindney (one) Kindney (one) 50 50 30 30 23 23 40 40 a 28 28 Klinisch manifeste Nephritis Klinisch manifeste Nephritis osophagus osophagus 60 60 58 58 55 55 72 72 70 70 68 68 Striktur, Perforation Striktur, Perforation 32 a 32 a 46 a 46 a Parotiden Parotiden 32 32 46 46 Xerostomie Xerostomie Rectum Rectum Volume: 100 cm Volume: 100 cm 3 60 60 Volume: 100 cm Volume: 100 cm 3 80 80 Proktitis, Stenose, Nekrose, Fistel Proktitis, Stenose, Nekrose, Fistel Retina (I+II) Retina (I+II) no Volume effect no Volume effect 45 45 no Volume effect no Volume effect 65 65 Blindness Blindness Rippen Rippen 50 50 65 65 Pathologische Fraktur Pathologische Fraktur Spinal Chord Spinal Chord 5 cm: 50 5 cm: 50 10 cm: 50 10 cm: 50 20 cm:47 20 cm:47 5 cm: 70 5 cm: 70 10 cm:70 10 cm:70 20 cm: 20 cm: - - Myelopathie, Nekrose Myelopathie, Nekrose Optic Nerve, Retinae (I+II) Optic Nerve, Retinae (I+II) no Volume effect no Volume effect 50 50 no Volume effect no Volume effect 65 65 Blindness Blindness

Tolerance doses ( Tolerance doses (Organ types) Organ types) Serial organs - example example Parallel organ - example example • Serial organs • Parallel organ spinal cord spinal cord lung lung What difference in What difference in High dose High dose response would you response would you region region expect? expect? Parallel Parallel organ organ High dose High dose region region Serial Serial organ organ In practice not always that In practice not always that clear cut clear cut

3-D D-Treatment planning process ( Treatment planning process (positioning) positioning) Fixation aids and markers on the skin Fixation aids and markers on the skin permit reproducibility of the settings by permit reproducibility of the settings by means of a stationary laser means of a stationary laser- coordinate coordinate system system Fixing of the treatment position Fixing of the treatment position (positioning, immobilization) (positioning, immobilization) Example: HNO Example: HNO-Area Area A technician A technician places the mask on the patient. places the mask on the patient.

3-D D-Treatment planning process ( Treatment planning process (positioning) positioning) Various tools for the Various tools for the positioning and positioning and immobilization: immobilization: Areas: Skull, chest, Areas: Skull, chest, Areas: Skull, chest, Areas: Skull, chest, abdomen, pelvis, upper abdomen, pelvis, upper and lower extremities. and lower extremities.

3-D D-Treatment planning process Treatment planning process (3-D Imaging) D Imaging) Fixing of the treatment position Fixing of the treatment position Example: HNO-Area Example: HNO Area planning CT planning CT (positioning, immobilization ) (positioning, immobilization CT The patient is positioned according to skin markers or anatomical reference The patient is positioned according to skin markers or anatomical reference points by using mechanical or optical viewing aids, but actually stationary laser. points by using mechanical or optical viewing aids, but actually stationary laser.

3-D D-Treatment planning process ( Treatment planning process (3D Imaging 3D Imaging - Fusion) Fusion) Fixing of the treatment position Fixing of the treatment position (positioning, immobilization) (positioning, immobilization) MRT CT PET SPECT Fusion 3-D CT data or optional PET D CT data or optional PET /MR images will be acquired. /MR images will be acquired. Image fusion serves for a better Image fusion serves for a better recognition of the target recognition of the target SPECT MRI CT

3-D D-Treatment planning process ( Treatment planning process (Contouring) Contouring) Fixing of the treatment position Fixing of the treatment position (positioning, immobilization) (positioning, immobilization) MRT CT PET SPECT Aquisition Fusion unit Contouring For the treatment planning, the For the treatment planning, the images must be exported from images must be exported from the acquisition unit and the acquisition unit and imported to the TPS unit. imported to the TPS unit. TPS unit