Hugues Mailleux Medical Physics Department Institut Paoli-Calmettes Marseille France. Sunday 17 July 2016

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1 Hugues Mailleux Medical Physics Department Institut Paoli-Calmettes Marseille France Sunday 17 July 2016

2 AGENDA 1. Introduction 2. Material 3. Optimization process 4. Results 5. Comments 6. Conclusion 7. Thanks

3 INTRODUCTION o Plan Competition: opportunity to evaluate our current treatment technique for left sided breast VMAT with 2 partial arcs First patient treated in september 2014

4 TREATMENT PLANNING SYSTEM o RayStation (RaySearch) r.5.0 Dose calculation for photon beams Collapsed cone convolution superposition algorithm GPU: Fluence + Convolution Plan Optimization Standard inverse planning Clinical goals

5 o Clinical goals TREATMENT PLANNING SYSTEM

6 ACCELERATOR o Versa HD (Elekta) Standard 6 MV MLC Agility

7 1. Beam geometry OPTIMIZATION PROCESS

8 ISOCENTER POSITION o o Not guided by dosimetric considerations but by technical constraints: Constraint n 1: CBCT The isocenter must be placed to avoid collisions

9 ISOCENTER POSITION o Constraint n 2: CBCT The isocenter must be placed to get the entire breast inside the field of view

10 ISOCENTER POSITION o Constraint n 3: Jaws and MLC maximum opening The isocenter must be placed to cover the entire PTV

11 BEAM GEOMETRY o No couch rotation o Gantry Arc 1: 170 ~ 300 Arc 2: ~ o Collimator : Arc 1: 5 Arc 2: 355 o Grid size: Plan Competition: 1,5 mm Current practice: 3 mm o Gantry spacing between 2 CP: 4

12 OPTIMIZATION PROCESS 1. Beam geometry 2. Create additional structures

13 ADDITIONAL OPTIMIZATION STRUCTURES

14 ADDITIONAL OPTIMIZATION STRUCTURES

15 ADDITIONAL OPTIMIZATION STRUCTURES

16 OPTIMIZATION PROCESS 1. Beam geometry 2. Create additional structures 3. Initial objectives

17 OPTIMIZATION PROCESS o Initial objectives

18 OPTIMIZATION PROCESS o Initial objectives

19 OPTIMIZATION PROCESS 1. Beam geometry 2. Create additional structures 3. Initial objectives PTV criteria OK?

20 INITIAL OBJECTIVES o Uniform dose and prescription Usually: 50 Gy to median dose (ICRU 84) in this case: 51,5 Gy to median dose

21 INITIAL OBJECTIVES

22 1. Beam geometry OPTIMIZATION PROCESS 2. Create additional structures 3. Initial objectives PTV criteria OK? 4. Add OAR objectives (weight = 1)

23 OAR CRITERIA o 2 types of criteria for OAR: maximum dose Rigth breast Spinal cord Parallel organs Heart Left lung Rigth lung

24 MAXIMUM DOSE CRITERIA o Maximum dose: o Rigth breast o Spinal cord

25 MAXIMUM DOSE : OAR OBJECTIVES o Additonal structures Breast rigth + 2 mm Spinal cord + 2 mm

26 PARALLEL OAR CRITERIA o Parallel OAR o Heart o Left Lung

27 PARALLEL OAR CRITERIA o Parallel type OAR dosimetric criteria o Rigth Lung:

28 PARALLEL OAR OBJECTIVES o Only one objectif by OAR o Initial weight: 1

29 3. Initial objectives (PTV, ring) OPTIMIZATION PROCESS 4. Add OAR objectives (weight = 1) 5. Fine-tune parallel OAR objectives clinical goals OK? 6. increase the weight of the OAR objectives End

30 HOW TO PUT THE MAXIMUM DOSE INSIDE DE CTV-LUMPECTOMY o Additional structure: PTV (CTV-LUMPECTOMY) Add objectives:

31 RESULTS

32 RESULTS Better!

33 DELIVERY TIME o Delivery time: Arc 1: 1 13 Arc 2: 1 18

34 PATIENT-SPECIFIC QA

35 PATIENT-SPECIFIC QA

36 COMMENTS: INTERFRACTION MOVEMENT

37 COMMENTS: INTERFRACTION MOVEMENT o How to take this into account? For fixed fields: skin flash VMAT?

38 o Virtual bolus COMMENTS: INTERFRACTION MOVEMENT

39 COMMENTS: INTERFRACTION MOVEMENT o Optimization: 2 step process 1) With virtual bolus: Optimization on the PTV OUTSIDE 2) After having removed the virtual bolus: Optimization on the PTV without modifying the shape of the segments

40 COMMENTS: INTERFRACTION MOVEMENT

41 COMMENTS o In our current technique, we use additional objectives for: Larynx Thyroid esophagus

42 CONCLUSION o Some (humble) recommendations: Well-defined methodology learning curve homogeneity of practices As simple as possible: 2 arcs No couch rotation As few objectives as possible for optimization Use of Virtual bolus

43 THANKS Ahmad Nobah Radiation Oncologists Medical Physics team RaySearch My Family

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