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The Royal Marsden
VMAT in thoracic malignancies
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Dr. Maria A. HawkinsConsultant Clinical Oncology
The Royal Marsden Hospital NHS FT
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Disclosure
received research funding from Elekta
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VMAT
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New technology competition
Cyberknife - good marketing, intracranial sites
Tomotherapy- all in one solution (IMRT only)
Protons-costly, not yet proven to be superior in certaintumour sites, not yet widely available
VMAT- linac based technology, more precise treatment,short delivery time, potentially more accessible
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Further evolution of IMRT
one/more gantry arcs
Continuously varying
VMAT
Beam aperture Gantry speed
Dose rate
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The Royal Marsden6Planning techniques-VMAT
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VMAT Benefits
Faster treatment times
Improved target dose conformality
Beam modulation
Reduced dose to OAR
3D volumetric imaging necessary for deliveryaccuracy
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Why speed matters?
Patient comfort
Intrafraction organ motion/Opportunity to use gating
o og ca e ec s- mprove c n ca ou comes
Patient throughput increased
Planning time - possibly faster once solution found
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Improved conformality/reduced OAR dose
Reduce toxicity further
Dose escalation
Hypofractionation
Re-treatment to radical doses
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3D volumetric imaging needed for VMAT
Improves accuracy
set-up margin reduction
Soft tissue visualization
Opportunity to adapt treatment if tumour/patient changesvolume/shape
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Tumour sites VMAT opportunities
Replace IMRT prostate/H+N/Gynae
Replace 3DCRT: GI-upper_lower/lung
SBRT: lung/liver/paraspinal
Palliative: vertebral body/H+N re-treatment
Other sarcoma, CNS
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VMAT lung cancer
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3D conformal vs IMRT vs VMAT
Planning study
5CT datasets of patients treated with radical RT fornon-small cell lung cancer
9 p ans IMRT 3, 5, 7, 9 fields coplanar
IMRT 3, 5, 7, 9 fields non-coplanar
VMAT
Brock ESTRO 2008
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3D conformal Radiotherapy
Brock ESTRO 2008
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IMRT plans VMAT
VMAT
5 F coplanar
7 F coplanar
Brock ESTRO 2008
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IMRT plans VMATFields arrangement
Brock ESTRO 2008
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PTV 95% isodose coverage
Brock ESTRO 2008
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Lung V20 comparison
Brock ESTRO 2008
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Inoperable stage III Non-small Cell Lung Cancer
Conformal plan
Bedford Acta Oncol 2008
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Inoperable stage III Non-small Cell Lung Cancer
VMAT plan
Bedford Acta Oncol 2008
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1st patient treatedCombined DVH
GTV
PTV
Lungs
Spinal cord
oesophagusheart
VMAT 3DCRT Bedford Acta Oncol 2008
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1st patient treated
Comparison of 3DCRT and VMAT
Parameter 3DCRT VMAT
PTV min 41Gy 43Gy
V20 35% 32%
Treatment time/# 180secs 90secs
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VMAT lung cancer
VMAT offers same degree of PTV coverage
Lung V20 similar
VMAT is preferable because of significant shortertimes
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VMAT oesophagus
cancer
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Oesophagus
Planning study 10 patients
Gastro-oesophageal junction
54Gy/30# Compared with 3D
Spare heart, liver, cord
Better conformity index
Hawkins BJR 2011
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Sagital plan comparison
Purple=PTVHawkins BJR 2011
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Fig. 1a
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Continuous=clinical
Dashed=VMAT
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40%
50%
60%
70%
at35Gy
Fig. 3
Heart volume receiving 35Gy
0%
10%
20%
30%
1 2 3 4 5 6 7 8 9 10
patient
%Volum
e
Clinical plan VMAT planHawkins BJR 2011
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OAR
Clinical plan VMAT p
Lungs V20 (%) 15%6% 15%5% 0.87
Mean lung dose (Gy) 8.22 9.72.7 0.02
Heart V35 (%) 44%14% 22%4% 0.01
Cord max (Gy) 35.81 29.55 0.02
Hawkins BJR 2011
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VMAT Oesophageal cancer
VMAT offers same degree of PTV coverage
Significant reduction of heart dose
VMAT is preferable because of significant shortertimes
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VMAT clinical data
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The Royal Marsden data thorax patients
34 patients treated between July 2008-June 2010
Age: mean 67 years (range: 43-89) Sex: M/F=17/8
Lung ca=28, dose 50-64Gy in 2Gy/#
ABC used in 11 lung patients 6 lung cancer SBRT part of study (not reported here)
oesophagus ca=6 with concurrent capecitabine 54Gyin 1.8Gy/#
Ahmed Hawkins 2011
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Lung and oesophagus DVH parameters
ORGAN VOLUME MEAN (RANGE)
Lung V5Gy
53.3 (17-92) %
(all patients) V10Gy 38.8 (8-76) %
V20Gy 18.1 (5-53) %
30Gy . -
V35Gy 7.6 (1-21) %
MLD 11.1 (3-19) Gy
Oesophagus V35Gy 22.3 (0-77) %
(lung patients only) V50Gy 13.5 (0-57) %
V60Gy 7.1 (0-49) %
Ahmed Hawkins 2011
h l d
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Acute toxicity (1-90days) Grade 1n=28
Toxicity grade Gr1 Gr2 Gr3
Dysphagia* 10% 33% -
Lethargy 8% 32% 1
Chest pain* - 3
Pneumonitis 29% 7% 3%
Pleural effusion 3 - -
Other Platelets 3.5%
Skin7%
Nausea 7%
Dyspnoea
PE
Pneumonia
*lung patients only Ahmed Hawkins 2011
Th R l M d6
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Acute toxicity (1-90days)
RT stopped early 4 cases
36Gy/50Gy platelets dropping 52Gy/64Gy Dyspnoea gr3
10Gy/64Gy PE
50Gy/64Gy brain metastases
All toxicities resolved at 3 months
Ahmed Hawkins 2011
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Localised pneumonitis 60Gy/8# at 3 mo post RT
Diagnostic CTPlanning and Dg CT fusion
Pink =PTV
Red=100%
Yellow=95%
Light green=70%
Brown=50%
Dark green=5%
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Conclusion
VMAT well tolerated
Pneumonitis rates were low Grade 2
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VMAT studies
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y
VISuAL Study:VMAT Image-guided Stereotactic
Arc therapy for small volumeLun tumours
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PI: Prof. M. Brada
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VISuAL Study
To assess the feasibility of delivery of
hypofractionated RT for early-stage NSCLC 60Gy/8#/3 weeks
using ABC / CBCT / VMAT
To assess associated toxicity andoutcomes
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First patient: VMAT plan
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First patient: CBCT & on line match
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First patient: CBCT & on-line matchPre match
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VMAT clinical implementation
Identify groups that benefit
Need to develop studies to confirm dose modellingpredictions
Keep the plan objectives and goals realistic!
Planning +verification ---more time
Faster delivery ---more patients
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Acknowledgements
Prof. Mike Brada
Helen McNairJuliet Brock
Judith Christian
James BedfordJim WarringtonFiona McDonaldMerina Ahmed
William Beaumont Hospital
Ellen DonovanPhil Evans
RMH Physics
RMH radiographers
RMH Imaging
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Thank you
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