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Course Objectives
After participating in this session, you will be able to:
Explain the benefit of using protons to treat stage III disease or
previously treated patients.
Identify patient selection criteria.
Discuss the simulation process and immobilization device
selection.
Describe techniques used in treatment planning.
Demonstrate the dosimetric advantages of Uniform Scanning
(US) proton therapy over photon therapy.
Illustrate the daily imaging and treatment delivery processes
specific to US protons
Lung cancer
GI cancers
Head and Neck cancers
and now, Breast cancer
The most difficult breast cancer sub-type to treat with traditional xray/photon radiation therapy, due to the inclusion of axillary,
supraclavicular, and internal mammary lymph nodes.
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Selection Criteria
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Differences:
Gantry room has most flexibility with treatment angles
Inclined beam room has fixed gantry angles of 30 or 90
degrees, but our technique for this room allows for most
enface setup.
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Gantry
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Gantry setup
Patient must be positioned
with both arms up in a
particle-friendly long vacloc or alpha cradle device.
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Patient Marks
Once the breast box has hardened, start making the
treatment marks on the patient and box.
Start with head position first: use the laser and have it
intersect the patients lips. Once this is done use a
marker and draw a line on the box to match; label as
lip line. If an arm is up mark on the patients elbow/
tricep area.
Find the SSN and set sagittal laser to boney anatomy.
Try to make sure the SSN and end of sternum match
with the laser.
Mark a three point set up on patient and box; about at
the end of the rib cage.
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CT Scan Specifications
Scan from top of head to below inframammary fold.
1.25 mm slice thickness
65 FOV used to get entire treatment device in scan (necessary for
checking for device collisions and to make sure a beam isnt
going through the device)
Cradle will need to be offset in bore to have all of affected side in
scan. Indexing bar with offset is utilized.
No 4D scan is necessary if magnitude of motion is less than
5mm. Breathing motion being in same direction as beam path.
First patients were done with 4D, but has been discontinued, as it
has been demonstrated to no longer be a concern and we want to
minimize excess dose for the patient.
MD places wires for clinical borders and on scar.
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Fusion
Fusions required:
Not usually, unless patient is on BRE-008 protocol. Then
fusion with CT Angiography study is require for cardiac
vessel delineation.
If patient was previously treated, then a deformable fusion is
done between the two treatment planning CTs. The
patients previous electronic DICOM radiation dose files are
requested for help with dose summation.
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MD Contours
MD will contour the CTV_50.4, which is comprised of the
ipsilateral supraclavicular nodes, chestwall/breast tissue, axillary
lymph nodes, and internal mammary lymph nodes.
RTOG guidelines for breast/chestwall and nodes are utilized, with
the exception that the entire ribs and chestwall are not included.
These areas were included in RTOG guidelines for simplicity, and
were not used to define regions of disease involvement, paths of
disease spread, nor regions at risk of reoccurrence.
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Dosimetrist Contours
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IBL
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LAO
beams
ASO
Beams
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Demonstration
of 1 set of the
ASO matching
fields to cover
the entire CTV.
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Junction Selection
Crucial to achieving an optimal treatment plan with
well-behaved compensators.
Select junction in region where the supraclavicular
nodes end and the chestwall volume begins.
Want to keep deep portion of nodal volume separate
from breast/chestwall region.
Drastic changes in depth within a compensator can
cause hot spots and steep ridges.
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Junction Selection
Matchline 1
Matchline 2
Air Gap = 10 cm
Air Gap = 25 cm
Plan Optimization
Once all beams are added, isocenters are set, air gaps
are finalized, and the junction areas are determined,
then:
Apertures are added to all beams, and optimized so 95% of
the PTV is covered laterally
Compensators are added, and tapered to remove any ridges
greater than 2 cm
Ranges and modulations are set to cover the CTV by the
100% ISL. Dose coverage specifications are that the D95%
of the CTV must equal 100% of the Rx, and the D99% must
equal 95% of the Rx.
Matchlines are tweaked so that the hot/cold areas are equal
in size
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Plan Optimization
Each beam is optimized so that the CTV coverage
constraint is met
Then, uncertainties are added to the range and
modulation for each beam
Our center uses 2.5% + 2 mm for the CT HU to stopping
power conversion uncertainty and cyclotron delivery
precision uncertainty
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Dosimetric Advantages of
Protons
In Isodose Distributions
Proton Doses
Photon Doses
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In Isodose Distributions
Proton Doses
Photon/Edoses
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In Isodose Distributions
Proton Doses
Photon/E- Doses
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In Isodose Distributions
Proton Doses
Photon/E- Doses
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Lt Breast
Photon/
E- Plan
Photon/E- Plan
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Proton
Plan
Photon/
E- Plan
Proton Plan
Photon/E- Plan
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Proton
Plan
Photon/
E- Plan
Proton Plan
Photon/E- Plan
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Patient Alignment
Alignment Process
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Conclusions
Will continue to offer proton therapy to these
subgroups of breast cancer patients, as the organ
sparing benefits have convinced us that this is a
worthwhile option for these patients.
Continue to look for ways to make the entire planning
process more efficient.
Other indications:
Partial Breast treatment for early stage treated 1 patient
per protocol thus far
Pencil Beam Scanning on the Gantry for the Stage III and
retreat patients
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References
PCG BRE-008 Cardiac-Sparing Post-Mastecomy Protocol
Ares, et al, Postoperative Proton Radiotherapy for Localized and
Locoregional Breast Cancer: Potential for Clinically Relevant
Improvements, Int. J. Radiation Oncology Biol. Phys. 76, No. 3,
pp. 685697(2010)
Fagundes, et al, Abstract poster presentation at PTCOG 2013
H. Paganetti: Range ncertainties in proton therapy and the impact
of Monte Carlo simulations, Phys. Med. Biol 57 R99-R107 (2012)
RTOG Breast Cancer Atlas for Radiation Therapy Planning:
Consensus Definitions
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Acknowledgements
Entire Physics and Dosimetry teams at ProCure
Chicago and Cadence Health.
The Breast Team: Rachel Sewell, RT(T), Dawn Smith,
RT(T), Megan Marshall, RT(T), Jennifer Mitchell, RT(T),
Stephanie Hufnal, RT(T) Minu Vachachira, RT(T),
Lauren Curran, RT(T), Hilary Deeke RT(T), Lindsey
Havron, RT(T)
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