IMRT & Stereotactic Radiotherapy

Christopher Golby
Principal Physicist, Christie Medical Physics & Engineering,
The Christie NHS Foundation Trust

15th May 2013

The Christie NHS

NHS Foundation Trust
 Contents
• 1. Introduction
• 2. Intensity Modulated Radiotherapy (IMRT)
• 2.1 Prostate IMRT
• 2.2 Head and Neck IMRT
• 2.3 Breast IMRT
• 3. Volumetric Modulated Arc Therapy (VMAT)
• 4. Stereotactic Radiotherapy
• 4.1 Radiobiology
• 4.2 Localisation & Delivery
• 5. Conclusion

The Christie NHS

NHS Foundation Trust
 1. Introduction

• Precisely locate the target

• Hold the target still
• Accurately aim the radiation beam
• Shape the radiation beam to the target
• Deliver a radiation dose that damages
abnormal cells, yet spares normal cells.

The Christie NHS

NHS Foundation Trust
2. Intensity Modulated Radiotherapy

The Christie NHS

NHS Foundation Trust
2. Intensity Modulated Radiotherapy

• What is IMRT?
• Type of radiotherapy where the intensity
of the beam is altered to produce
concave dose distributions
• Extension of using a wedge to improve
dose conformity.

The Christie NHS

NHS Foundation Trust
2. Intensity Modulated Radiotherapy

• What does it do?

• Sculpts the dose around the shape of
the disease.
• Increases potential for dose escalation
and/or normal tissue dose reduction.

The Christie NHS

NHS Foundation Trust
 Target

OAR

Non modulated fields

Compare high dose close to OAR

The Christie NHS

NHS Foundation Trust
 High intensity

Intensity/Fluence

The Christie NHS

NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
 2.1. Prostate IMRT

• Rectum is the dose limiting organ at risk

for prostate radiotherapy.
• Rectum is in close proximity to the GTV
and often ends up close to or inside the
PTV
• IMRT aims to reduce dose to rectum whilst
maintaining or escalating dose to some or
all of the PTV.

The Christie NHS

NHS Foundation Trust
Prostate IMRT - CHHIP

PTV3 >95%

PTV2 >91%

PTV1 >76%

Dose
levels
•57Gy/19
•60Gy/20
•74Gy/37

The Christie NHS

NHS Foundation Trust
2.1. Prostate IMRT

The Christie NHS

NHS Foundation Trust
 2.2. Head & Neck IMRT

 Critical structures in
head & neck treatments.
 Potential side effects:
Paralysis, blindness,
hearing loss, loss of salivary
function.

The Christie NHS

NHS Foundation Trust
Parotid Sparing in Hypo/Oropharanyx
Treatments
•Aim to reduce side-effects
of conventional treatment
(xerostomia, hearing loss).
• Need to keep dose to brain
and brain stem as low as
possible
•Multiple dose levels

ICR / RMH London

The Christie NHS

NHS Foundation Trust
2.2. Head & Neck IMRT

The Christie NHS

NHS Foundation Trust
 2.3. Breast IMRT

 It is not possible to choose a wedge that

compensates exactly for the constantly
changing contour of the breast.
 This leads to large inhomogeneity of dose
within the patient which has been linked to
poor cosmesis (particularly for larger
breasts).
 IMRT offers a method for improve dose
homogeneity with a few IMRT segments.
The Christie NHS
NHS Foundation Trust
 2.3. Breast IMRT
115%, 110%, 105%, 100%, 95%, 90%

Standard Wedges with Lung IMRT with an MLC Lung Block

Correction
The Christie NHS
NHS Foundation Trust
2.3. Breast IMRT

The Christie NHS

NHS Foundation Trust
3. Volumetric Modulated Arc Therapy
(VMAT)

The Christie NHS

NHS Foundation Trust
3. Volumetric Modulated Arc Therapy
(VMAT)
• Everything can move!

• Gantry speed
• MLC leaves & Jaws
• Dose Rate
• Collimator angle

The Christie NHS

NHS Foundation Trust
3. Volumetric Modulated Arc Therapy
(VMAT)

The Christie NHS

NHS Foundation Trust
3. Volumetric Modulated Arc Therapy
(VMAT)
• Better patient treatments

• Reduced long term side effects - patient

safety

• Increased speed of delivery – patient

comfort, compliance & throughput

The Christie NHS

NHS Foundation Trust
3. Volumetric Modulated Arc Therapy
(VMAT)

The Christie NHS

NHS Foundation Trust
4. Stereotactic Radiotherapy

The Christie NHS

NHS Foundation Trust
 4. Stereotactic Radiotherapy

• Traditionally refers to cranial sites with

small targets, but has more recently been
extended to extracranial sites (e.g. spine,
liver, lungs) - SABR
• Precisely locate the target and deliver high
doses in small numbers of fractions

The Christie NHS

NHS Foundation Trust
 4.1. Radiobiology

Radiobiology of Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Chang W. Song,
Heonjoo Park,
Robert J. Griffin,
Seymour H. Levitt

The Christie NHS

NHS Foundation Trust
 4.2 Localisation & Delivery

• Localisation methods:
• Rigid frame so no imaging required (e.g.
Gamma Knife)
• Frameless using planar kV (e.g.
Brainlab Novalis)
• SABR using XVI imaging (e.g. isolated
lung lesions)

The Christie NHS

NHS Foundation Trust
 4.2.1 Rigid frame – no imaging

• E.g. Gamma Knife or older linac based

systems.

The Christie NHS

NHS Foundation Trust
http://www.internationalgammaknifeclinic.com/

The Christie NHS

NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
 4.2.2 Frameless with kV imaging

• E.g. linac based Brainlab Novalis and

Exactrac

The Christie NHS

NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
4.2.3. Extracranial with XVI imaging

• E.g. isolated lung lesions, spine, liver

• Stereotactic Body Radiotherapy (SBRT)
• Steretactic Ablative Radiotherapy (SABR)

• Currently treat only isolated lung lesions at

the Christie with this technique

The Christie NHS

NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust
Lots of imaging!

The Christie NHS

NHS Foundation Trust
5. Conclusion

The Christie NHS

NHS Foundation Trust
 SABR using VMAT

• 54Gy in 3 fractions
• VMAT offers shorter delivery time than
conventional treatment (45 minute treatment slot)
• Single arc coplanar delivery reduces treatment
time considerably – better patient compliance,
less motion
Plan Total MUs No. of Treatment time Coplanar
beams (after patient
set-up)
Conventional 2163 11 ~25 mins No
VMAT 2139 91 ~5 mins Yes
The Christie NHS
NHS Foundation Trust
 The Christie NHS
NHS Foundation Trust