The MSKCC Approach to IMRT. Outline

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1 The MSKCC Approach to IMRT Spiridon V. Spirou, PhD Department of Medical Physics Memorial Sloan-Kettering Cancer Center New York, NY Outline Optimization Field splitting Delivery Independent verification for IMRT Examples Prostate Nasopharynx Whole Abdomen 1

2 Optimization Quadratic objective function Gradient minimization methods Smoothing Multiple loops Other features: Optimization over a pre-existing distribution The Objective Function N pts ( Di Dpresc ) 2 i= 1 N pts 1 F = + w Di D 2 target min ( min ) N pts i= 1 N pts + w Di D 2 max ( max ) i= 1 Prescription dose Homogeneity terms included only if constraint violated F organ = max dose constraint + dv constraint Volume V dv D dv Dose 2

3 Smoothing of Intensity Profiles Local fluctuations in intensity profile due to numerical artifacts. Little or no dosimetric advantage. Difficult to deliver, requires longer beam-on time. Susceptible to treatment uncertainties. without smoothing Smoothing of Intensity Profiles Savitzky-Golay (least squares fit) before smoothing after smoothing 3

4 Smoothing included as part of the Objective Function Fobj = wi i target + wi i OAR + w j j beam ( D D ) i 2 ( D D ) i 2 ( x x ) ' j p c j 2 For over & under dose in the targets For over dose in critical organs, may include dose-volume conditions For smoothness in intensity profile x j : value before smoothing x j : value after smoothing Comparison of Smoothing Approaches Smoothing outside the objective function Gentler gradients, fewer MU. Cannot distinguish between noise and dosimetrically relevant fluctuations. Smoothing within the objective function Dosimetric effect of smoothing taken into account: heavier smoothing for noise, lighter for dosimetrically relevant fluctuations. Higher profile modulation, more MU 4

5 Example 1: Phantom OAR 5 Smoothing at the end of each iteration Smoothing within the objective function Example 2: Paraspinal ~ 5mm separation Cord Goal: Given that 95% of the must receive the prescription dose, what is the best Cord protection that can be achieved? 5

6 Paraspinal Cord Smoothing at the end of each iteration Smoothing within the objective function Paraspinal 120 Smoothing within the objective function Smoothing at the end of each iteration Volume (%) Cord Dose (%) 6

7 Multiple loops More accurate incorporation of scattered dose in optimization For efficiency, scattered dose is only partially accounted for in optimization. Discrepancy with full-scatter dose calculation. Repeated cycles of optimizations and full-scatter dose calculations required to achieve optimal results. Volume (%) Cord Dose (%) Optimization Full scatter dose calc. More accurate incorporation of scattered dose in optimization: Iterative correction process Correction factor C i = 0 Optimization based on partial scattered dose calculation P i Intensity profiles Total dose D i = P i + C i Update C i = C i + δ i N δ i = F i -D i δ i < tolerance? F i calculated with full scattered dose Y done 7

8 More accurate incorporation of scattered dose in optimization: Iterative correction process Volume (%) Cord Volume (%) Cord Dose (%) No correction Dose (%) With correction Optimization Full scatter dose calc. Splitting Large IM Fields Considerations for automatic splitting Smooth subfields - no discontinuities. Split along a straight line or at a region of low intensity. Use feathering to reduce the effects of positioning uncertainties. Sub-fields should be designed to minimize beam-on time (MU). 8

9 Splitting Large IM Fields Example: nasopharynx PA field Before splitting After splitting Splitting Large IM Fields Example: nasopharynx PA field Leaf Pair Intensity (MU) 10 5 Intensity (MU) X (cm) X (cm) Before splitting After splitting 9

10 Leaf Sequencer DMLC - Sliding window Accounts for: Mechanical limitations (e.g. leaf speed) Direct exposure Transmission through the leaves Rounded leaf-ends Scatter source Intensity under the leaves beam I(x) 1 P 1 : direct exposure P 2 : leaf rounded end P 3 : leaf transmission ε P 1 P 2 P 3 x 10

11 Variation of Output with Field Size Backprojection to the source plane Primary Source Scatter Source Source plane left leaf right leaf MLC opening MLC plane P P Isocenter plane Iterative process to generate leaf paths Desired fluence profile F(x) Assign F work (x) = F(x) Calculate leaf paths using F work (x) Modify working profile F work (x) = F work (x) - E(x) Calculate generated profile F g (x) taking all factors into account Calculate error E(x) = F g (x) - F(x) N error acceptable? Y finish 11

12 Independent verification for IMRT (a regulatory requirement) A separate program Input: Leaf sequencing file Beam-on time Jaw settings Beam data Factors accounted for: Rounded leaf ends Leaf transmission Tongue-and-groove Scatter source MLC scatter Output: Dose to points or planes in phantom Calculation Measurement Prostate Similar anatomically and geometrically Prescription dose: 8640 or 8 cgy Fixed beam angles - 5 fields Template of optimization parameters and constraints 12

13 Prostate 8 cgy Rectum Volume (%) Rectum Bladder Dose (%) Nasopharynx Prescription dose: 5400 cgy to microscopic disease 7000 cgy to gross disease Fixed beam angles - 7 fields 9 or 10 fields after splitting Template of optimization parameters and constraints 13

14 Nasopharynx 7000 cgy 80 Volume (%) Bstem Cord R. parotid Dose (cgy) Cord Parotid Whole Abdomen Conventional treatment: AP/PA, 6MV, extended distance Prescription dose: 3000 cgy Blocks to keep kidneys at 1800 cgy IMRT 5 fields, 15MV, isocentric Large fields: 2 isocenters, split fields in 3 Large volumes: little scatter accounted for in optimization (use multiple loops ) 14

15 Whole Abdomen 325 Ant x Abdominal ISO Lt PA 15 MV 180 x Pelvic ISO Abdominal PA field Superior Left kidney Right kidney Right Junction 15

16 Abdominal PA Field: Beam Splitting Middle Part Left Part Right Part Whole Abdomen: Sagittal plane Abdominal ISO Homogeneous Dose Distribution in Junction Pelvic ISO 16

17 Whole Abdomen: Coronal plane Abdominal ISO Homogeneous Dose Distribution in Junction Pelvic ISO Whole Abdomen Pelvic bones IMRT Conventional 17

18 References Hong L et al. IMRT of Large Fields: Whole Abdomen Irradiation. Int J Radiat Oncol Biol Phys in press. Hong L et al. Intensity-modulated tangential beam irradiation of the intact breast. Int J Radiat Oncol Biol Phys 44: (1999). Hunt MA et al. Evaluation of concave dose distributions created using an inverse planning system. Int J Radiat Oncol Biol Phys in press. Hunt MA et al. Treatment planning and delivery of intensity-modulated radiation therapy for primary nasopharynx cancer. Int J Radiat Oncol Biol Phys 49: (2001). Chui CS et al. Delivery of intensity-modulated radiation therapy with a conventional multileaf collimator: comparison of dynamic and segmental methods. Med Phys 28: (2001). Chui CS et al. A simplified intensity modulated radiation therapy technique for the breast. Med Phys 29: (2002). Burman C et al. Planning, delivery, and quality assurance of intensity-modulated radiotherapy using dynamic multileaf collimator: a strategy for large- scale implementation for the treatment of carcinoma of the prostate. Int J Radiat Oncol Biol Phys 39: (1997). References Ling CC et al. Conformal radiation treatment of prostate cancer using inverselyplanned intensity-modulated photon beams produced with dynamic multileaf collimation. Int J Radiat Oncol Biol Phys 35: (1996). LoSasso T et al. Comprehensive quality assurance for the delivery of intensity modulated radiotherapy with a multileaf collimator used in the dynamic mode. Med Phys 28: (2001). LoSasso T et al. Physical and dosimetric aspects of a multileaf collimation system used in the dynamic mode for implementing intensity modulated radiotherapy. Med Phys 25: (1998). Spirou SV and Chui CS. Generation of arbitrary intensity profiles by dynamic jaws or multileaf collimators. Med Phys 21: (1994). Spirou SV and Chui CS. A gradient inverse planning algorithm with dose-volume constraints. Med Phys 25: (1998). Spirou SV et al. Smoothing intensity-modulated beam profiles to improve the efficiency of delivery. Med Phys 28: (2001). Zelefsky MJ et al. Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 55: (2000) 18

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