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3D PLANNING TREATMENT IN

HEAD & NECK

Lakbir EL HAMIDI
Medical Physicist
National Institute of Oncologie, Rabat - Morocco

Regional (AFRA) training course on Head & Neck cancer


Rabat : 20 June 2007
PLAN

Introduction
Treatment Planning System
Simulation, Image acquisition, Beam
definition and Field shaping
Qualitative treatment plan Evaluation
Quantitative treatment plan Evaluation
Treatment Delivery control
Conclusion
INTRODUCTION
Several organs at risk in head and neck region are
usually in close proximity to the tumor

Brain stem, Spinal cord,


Parotid glands, Optic
nerves, Optic chiasma,
Retina,
Lymph nodes,
Tumor

This spatial characteristic makes radiation


therapy for Head and Neck a very
challenging task
INTRODUCTION

Tumors originating in the pharyngeal wall


are usually concave and wrap around the
spinal cord, and the parotide gland is in
the proximity to the lymph nodes

Tumors arising from the paranasal


sinuses often invade the space adjacent
to the optic nerves or optic chiasma
INTRODUCTION

These critical organs can receive


radiation doses in the range of 30 60
Gy without causing complications

however

The dose needed to control gross tumor


often exceeds 70 Gy
INTRODUCTION

The ability to deliver tumor doses to the


target volume while maintaining low doses to
the critical organs can be achievable with :

3D treatment planning
Conformal Radiation Therapy
Intensity Modulated Radiation Therapy (IMRT)
Image Guided Radiation Therapy (IGRT)
Tomotherapy

TREATMENT PLANNING SYSTEM

In most 2D treatment planning, many


important decisions involved in patient
treatments are made externally to TPS

For example, beam directions, field


sizes, blocking, and other issues are
determined during simulation

The development and clinical use of


3D treatment planning system has
significantly affected the scope and
approch of patient treatment
TREATMENT PLANNING SYSTEM

Data mesurement Data imaging

Traitement plan
TREATMENT PLANNING SYSTEM

All the available imaging methods may


contribute to the acquisition of the
detailed anatomical information required
for 3D treatment planning

Dose calculation formalisms necissitate


that the anatomical information be
presented in terms of electron density
ratios, which can be obtained only from
computerised axial tomography (CT)
images
TREATMENT PLANNING SYSTEM

Magnetic Resonance Imaging (MRI) or


other imaging modality studies may
provide complementary information on
tumor volume and adjacent normal
organ definitions

Integration of image based anatomic


data beams eye view (BEV) displays
allows a 3D appreciation of conformal
beam edges to both tumor and normal
tissues
TREATMENT PLANNING SYSTEM

Permits the use of non coplanar


beams. These non axial beams often
treat less critical normal tissue than
traditional axial beams

Correlation of 3D dose distribution


with patient anatomy can lead to
better understanding the relationship
between normal tissue volume and
toxicity
DOSE CALCULATION ALGORITMS

to predict with as much accuracy as possible


dose delivered to any point within the patie

Matrix representation
Separation of primary and scatter
(Clarkson)

Pencil beam algorithms


Monte Carlo methods
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING
Conventional simulators are used to
determine the treatment position of
the patient, to define a provisional
isocenter and to produce reference
localization skin marks
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

A thermoplastic facial masks for Head


& Neck are made to ensure that the
patient can be positioned for planning
and treatment in reproducible fashion
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING
CT scans are subsequently obtained with
the patient in the immobilization device

Alignement lasers in the scanner room


are matched to the skin marks

To produce high resolution 3D


reconstructions, consecutive CT images
with 3-5 mm slice thickness are obtained
from approximately 3cm above to 3cm
below the target volume. Additional
images with a slice thickness of 1cm
above and below
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

VOLUMES (ICRU 62):


GTV: gross tumour volume
CTV: clinical target volume
PTV=IM+SM: planning target
volume
IM: internal margin
SM: set-up margin

PRV: planning organ at risk


volume
TV: treated volume
IV: irradiated volume
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

Contours of the target and


surrounding normal tissues are
drawn manually from the
simulation CT slices using TPS
tools

The contours of body surface,


lungs, head & neck air cavities
and bony structures can be
outlined automatically using an
edge detection algorithm
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

Critical organs of interest :


spinal cord retinas
brain stem lenses
temporal lobes parotid glands
optic chiasma mandible

were contoured on multiple


slices
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

The target volume and the normal


organ images required for treatment
planning and plan evaluation are
reconstructed in 3D
displayed with and
the
Beams Eye View
technique using color
to distinguish
different anatomical
structures
SIMULATION, IMAGE ACQUISITION,
BEAM DEFINITION & FIELD SHAPING

Beam apertures
for blocks or MLC
are automatically
shaped by
applying a
needed margin
QUALITATIVE EVALUATION

Target coverage and critical normal


tissue doses are evaluated by
examining isodose surface
distributions on 2-D midplane axial,
sagittal, and coronal CT images
Region of overdose to
normal critical
structures or underdose
to the target volume
may be identified
QUANTITATIVE EVALUATION

Cumulative and differential dose-


volume histograms (DVH) are the most
useful numerical treatment plan
evaluation method
QUANTITATIVE EVALUATION

DVHs are generated for the


tumor and for each organ of
interest depending on the
site treated, and
compilations of such curves
are used for comparing
treatment plans

DVHs are useful for


evaluating and comparing
rival treatment plans and for
making therapeutic decisions
TREATMENT DELIVERY CONTROL

Lateral and anterior digitally


reconstructed radiographs (DRRs) of
the patient in the treatment position
were generated on a TPS
TREATMENT DELIVERY CONTROL

Before starting treatment, 4cm wide


strip portal imaging, centered at the
plan origin, were obtained at 0 and
270 gantry angles and were compared
with corresponding DRRs to ensure
satisfactory reproducibility of patient
immobilization
CONCLUSION

3D technique improves target coverage

Reduces the volume of normal tissue


receiving high radiation dose

Decreases acute normal tissue morbidity

Permits Dose Escalation and consequently


high local control rate and survival
Lakbir EL HAMIDI