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Direttore Prof. Marcello Benassi

STRUTTURA COMPLESSA LABORATORIO DI FISICA MEDICA E SISTEMI ESPERTI IRE - ROMA. Direttore Prof. Marcello Benassi. POSITIONING ACCURACY WITH EXACTRAC X-RAY: OUR EXPERIENCE. Dott. Vicente Bruzzaniti. EXTERNAL BEAM RADIOTHERAPY: SOME PROBLEMS. 1. Clinical uncertainties.

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Direttore Prof. Marcello Benassi

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  1. STRUTTURA COMPLESSA LABORATORIO DI FISICA MEDICA E SISTEMI ESPERTI IRE - ROMA Direttore Prof. Marcello Benassi Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  2. POSITIONING ACCURACY WITH EXACTRAC X-RAY: OUR EXPERIENCE Dott. Vicente Bruzzaniti Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  3. EXTERNAL BEAM RADIOTHERAPY: SOME PROBLEMS 1. Clinical uncertainties 2. Geometrical uncertainties Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  4. DIFFICULTIES IN IDENTIFYNG THE TARGET VOLUME FROM CT SLICES IDENTIFICATION OF GROSS TUMOR VOLUME (GTV) AND CLINICAL TUMOR VOLUME (CTV)ACCORDING TO ICRU REPORT 50 Clinical uncertainties Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  5. Geometrical uncertainties Internal motion Patient Positioning Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  6. INTERNAL ORGAN MOTION DURING ENTIRE TREATMENT IDENTIFICATION OF INTERNAL TARGET VOLUME (ITV) Geometrical uncertainties due to internal organ motion INTERNAL TARGET VOLUME(ITV) = CLINICAL TARGET VOLUME (CTV) + INTERNAL MARGIN (IM) ACCORDING TO ICRU REPORT 62 Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  7. PROBLEMS IN OBTAINING COINCIDENCE BETWEEN PLANNING ISOCENTER AND LINAC ISOCENTER DURING PATIENT POSITIONING IDENTIFICATION OF PLANNING TARGET VOLUME (PTV) Geometrical uncertainties due toPatientPositioning PLANNING TARGET VOLUME(PTV) = INTERNAL TARGET VOLUME (ITV) + SETUP MARGIN (SM) ACCORDING TO ICRU REPORT 62 Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  8. We need to In a perfect world….. SM 0 DOSE ESCALATION: higher Tumor Control ProbabilityBUT higher Normal Tissues Complications Probability Exclude as much healthy tissue as possible from irradiated zone: MARGIN REDUCTION HIGHER POSITIONING ACCURACY SM=0 PTV=ITV Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  9. Original margin Reduced margin Example: IMRT allows for better isodose conformation to desired target shape. Allows forbetter sparing of critical structures ONCE GIVEN a higher accuracy in patient positioning (SM0 , PTVITV) Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  10. TO OBTAIN A HIGHER POSITIONING ACCURACY: MEGAVOLTAGE EPID EXACTRAC SYSTEM Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  11. EXACTRAC SYSTEM EXACTRAC INFRARED MODULE Remote IR-guided Couch Control Stand- alone As a tool for EXACTRAC X-RAY MODULE Patient positioning using external IR reflecting markers Patient positioning using internal structures as markers Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  12. Our investigation: Verification of Exactrac X rays positioning accuracy in prostate treatment with prone patients Comparisons between portal films taken at 0 - 90° gantry position and corresponding DRRs from Brainscan TPS Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  13. ExacTrac X-Ray Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  14. EXACTRAC INFRARED COMPONENTS CT identifiable Can be place everywhere IR REFLECTING SKIN MARKERS IR CAMERAS IR markers guide VIDEO CAMERA Permanent room and patient monitoring Exactrac-Linac Integration Couch control from outside treatment room REMOTE COUCH CONTROL Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  15. FLAT PANEL EXACTRAC INFRARED INTEGRATION COMPONENTS: EXACTRAC X-RAYS COMPONENTS X-RAYS SOURCE X RAY TUBE (150 kVmax) Amorphous Silicon detector Radiological Images Acquisition NEEDED COMPONENT FOR BOTH SISTEMS RT Planning computation and evaluation Isocenter coordinates export DRRs computation along X-rays tubes directions TPS – BRAINSCAN Brain Lab LTD Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  16. PATIENT ARRANGEMENT PREVIOUS TO CT ACQUISITION DEFLATION OF PERSONAL VACUUM CUSHION IR REFLECTING SKIN MARKERS PLACING Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  17. CT SCANNING OF PATIENT WITH IR REFLECTING MARKERS DICOM IMAGES TRANSFER TO TPS (BRAIN SCAN-BRAIN LAB) SKIN MARKERS DETECTION FROM TPS (BRAIN SCAN: localization) FROM BRAINSCAN TPS (LOCALIZATION) 3D RECONSTRUCTION OF SKIN MARKERS DISTRIBUTION Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  18. PLANNING AND PLAN VALIDATION APPROXIMATE POSITIONING OF PATIENT AT ISOCENTER AND BEGINING OF AUTOMATED EXACTRAC POSITIONING PROCEDURE Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  19. PROCEDURE Flat panel Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  20. PROCEDURE Automatic couch displacement for first radiogram acquisition Pos. 1 Flat panel Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  21. PROCEDURE Automatic couch displacement for second radiogram acquisition Pos. 1 Pos. 2 Flat panel Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  22. DRR’s COMPUTATION ALONG X-RAY TUBES DIRECTIONS USING PATIENT’S CT DATA COMPARISON BETWEEN DRRs AND RADIOGRAPHIC SHOTS Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  23. ISOCENTER POSITION SEARCH BY MEANS OF IMAGE FUSION BETWEEN RADIOGRAMS AND CORRESPONDING DRRs Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  24. PATIENT POSITIONING AT ISOCENTER COUCH POSITIONING ACCORDING TO CALCULATED SHIFT MATCH Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  25. Definition of evaluated quantities • Sistematic setup error on single patient: average of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Random setup error on single patient: standard deviation of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Method Error on patient population: average of errors given in 1 • Sistematic setup error on patient population: standard deviation of errors given in1 • Random setup error on patient population: standard deviation of errors given in2 Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  26. POSITIONING ACCURACY WITH EXACTRAC X-RAY: OUR EXPERIENCE RESULTS Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  27. RANDOM ERRORS slong = 0,9 mm sant post = 0,8 mm RANDOM ERROR ON POPULATION slat lat = 1,1 mm Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  28. METHODERROR long= -0,3 mm ant post= 0,8 mm lat lat= -0,8 mm SISTEMATIC ERRORS AND METHODERROR slong = 1,3 mm sant post = 1,6 mm SISTEMATIC ERROR ON POPULATION slat lat = 1,5 mm Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  29. Dott MARCO D’ANDREA Prof. MARCELLO BENASSI REGARDS Prof. GIORGIO ARCANGELI Dott. GIUSEPPE GIOVINAZZO Sig VINCENZO LUNGHI Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  30. FINE Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  31. Definition of evaluated quantities • Sistematic setup error on single patient: average of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Random setup error on single patient: standard deviation of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Method Error on patient population: average of errors given in 1 • Sistematic setup error on patient population: standard deviation of errors given in 1 • Random setup error on patient population: standard deviation of errors given in2 Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

  32. Definition of evaluated quantities • Sistematic setup error on single patient: average of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Random setup error on single patient: standard deviation of measured difference in isocenter position between 0-90 portal films and computed DRRs on brainscan • Method Error on patient population: average of errors given in 1 • Sistematic setup error on patient population: standard deviation of errors given in1 • Random setup error on patient population: standard deviation of errors given in 2 Evolving Strategies in Radiation Oncology - "Setup Accuracy with Exactrac" Laboratorio di Fisica Medica e Sistemi Esperti IFO - Dott Vicente Bruzzaniti

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