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Dosimetric comparison of SBRT for

lung cancer: Cyberknife vs. Linac

Chuxiong Ding,
Ding Ph.D.,
Ph D Cheng-Hui
Cheng Hui Chang
Chang, Ph
Ph.D.,
D Joshua Haslam
Haslam,
Ph.D., Robert Timmerman, M.D., Timothy Solberg, Ph.D.

Department of Radiation Oncology,


University of Texas Southwestern Medical Center, Dallas, TX

DEPT OF RADIATION ONCOLOGY


History of Stereotactic Radiosurgery

Single large radiation dose.


Multiple non-coplanar beams.
beams
Accurate targeting.
Leksell L, A stereotaxic apparatus for
intracerebral surgery,
surgery Acta Chir Scand.
Scand
99:231, 1949

DEPT OF RADIATION ONCOLOGY


E l ti off T
Evolution Technological
h l i l IInnovation
ti

Lung, Liver, Pancreas, Prostate, Spine


DEPT OF RADIATION ONCOLOGY
Stereotactic Body Radiation
Th
Therapy (SBRT)
• Radiation delivery to a demarcated tumor target
using:
i
optimal immobilization
motion accounting
many small fields
accurate targeting
g g
heterogeneous target dose
steep dose gradients outside targets
ablative intent
few large dose treatments

DEPT OF RADIATION ONCOLOGY


Conformal high dose
Prescription Dose: 60Gy in 3 fractions

Target 60Gy 30Gy 7.5Gy

DEPT OF RADIATION ONCOLOGY


Challenges for lung tumor SBRT
t t
treatment t
• Localization

• Respiratory Motion

Inhalation Exhalation MIP

Tumor excursion Diaphragm excursion


DEPT OF RADIATION ONCOLOGY
Purpose of Study
IGRT technique
Immobilization
Linac used
Collimator
Respiration
Compensation
Treatment
planning system
etc.

Dosimetric
Difference
DEPT OF RADIATION ONCOLOGY
Linac Based Lung Cancer SBRT-
SBRT-
T
Tumor Localization
L li ti
• SBRT Frame: immobilization,, localization.

• Cone Beam CT

DEPT OF RADIATION ONCOLOGY


Linac Based Lung Cancer SBRT-
SBRT-
Respiratory
R i t M
Motion
ti C Control
t l
• Large margin to GTV, Gating, ABC, Abdominal
Compression, etc.
Playba
Breathing Signal ck
Upper Threshold Indicat
or

Lower Threshold
Beam On /
Off
Indicator
GTV PTV

DEPT OF RADIATION ONCOLOGY


Cyberknife Lung Cancer SBRT-
SBRT-
T
Tumor Localization
L li ti
• Sophisticated image guidance tumor Localization

DEPT OF RADIATION ONCOLOGY


Cyberknife Lung Cancer SBRT-
SBRT-
Respiratory
R i t M
Motion
ti C Control
t l
Internal Fiducial Markers External Optical Markers

DEPT OF RADIATION ONCOLOGY


Clinical SBRT Procedure in UTSW

0%

50%

90%

4DCT MIP for contour Tx Planning QA

Dose Delivery CBCT Alignment Patient Setup


DEPT OF RADIATION ONCOLOGY
SBRT Dose prescription in UTSW
RTOG 0236
A Phase II Trial of Stereotactic Bodyy Radiation Therapy
py ((SBRT)) in the
Treatment of Patients with Medically Inoperable Stage I/II Non-Small Cell
Lung Cancer

Prescription: 60Gy in 3 fractions.

60--90% isodose line cover at least 95% of PTV.


60

99% of PTV should receive a minimum of 90% of


prescript dose
dose.
Parallel Tissue Critical Volume (cc) Critical Volume Endpoint (≥Grade 3)
Dose Max (Gy)
Lung (Right & Left) 1000 cc 13.5 Gy Pneumonitis

DEPT OF RADIATION ONCOLOGY


Target Definition

Inhalation Exhalation MIP

Tumor excursion Diaphragm excursion

PTV3D GTV

ITV PTV4D
DEPT OF RADIATION ONCOLOGY
Study Protocol GTV
PTV4D

Radiation Respiratory PTV3D


Start Timingg Cycle
ITV
4D CT Study

0% … 50% … 90%
Synchrony
ITV, PTV3D, MIP, and
AVG images

4D calculation
GTV, PTV4D,
50% phase CT

0%
% 50%
% 90%
%

… …

Deformable Registration

50% phase

GTV
DEPT OF RADIATION ONCOLOGY PTV4D
Result (1): Dose to Tumor
Patient 1
1 a

0.8

GTV C b
GTV_Cyber
0.6 b
Volume

PTV4D_Cyber
GTV SBRT
PTV4D SBRT
0.4

0.2

c
0
0 20 40 60 80

Dose (Gy)

• Tumor coverage
• Tumor dose homogeneous
DEPT OF RADIATION ONCOLOGY • Maximum Dose
Result (1): Dose to Tumor
DHI for GTV Maximum point dose to
(D20-D
D80)/Dprespcription GTV (Gy)

Cyberknife Linac Cyberknife Linac Patient 1


1
10.09 2.31 78.2 70.3
0.8
72.4 72.2
9.01 3.51 GTV_Cyber Linac

Volume
0.6 PTV4D_Cyber
5.93 2.38 74.3 66.9 GTV SBRT
PTV4D SBRT
0.4

11.28 5.43 75 2
75.2 71 3
71.3
0.2
Cyber
6.24 5.84 73.3 73.2
0

8.36 2.17 77.1 68.1 0 20 40 60 80

Dose (Gy)
(G )

8.62 2.61 73.3 73.2

10.13 2.53 76.2 70.2

75 0±2 0
75.0±2.0 70 7±2 3
70.7±2.3
8.71±1.87 3.35±1.47

DEPT OF RADIATION ONCOLOGY


Result (1): Dose to Tumor

7~10 beams More Than


100 Beams

Patient 1
1

0.8

GTV_Cyber
0.6
Volume

PTV4D_Cyber
GTV SBRT
PTV4D SBRT
0.4

0.2

0
0 20 40 60 80

Dose (Gy)
DEPT OF RADIATION ONCOLOGY
Result (2): Dose to Lung
Institutional Dose Limit for Lung
SBRT: 1000cc lung get less than
13.5Gy

V20

Dose to
1000cc Lung

DEPT OF RADIATION ONCOLOGY


Result (2): Dose to Lung
Minimum Dose to 1000cc Lung

10.00
9.00
Anterior Middle Posterior
8.00
7.00
6 00
6.00
y)
Dose (Gy

Cyberknife
5.00
Linac SBRT
4.00
3.00
2.00
1.00
0.00
1 2 3 4 5 6 7 8
Patients

vs.

DEPT OF RADIATION ONCOLOGY


Result (2): Dose to Lung
Patient VPTV4D V20
Cyberknife Linac
1 0.34% 1.34% 3.27%
2 1.19% 3.67% 3.11%
V20
3 0.91% 4.31% 4.90%
4 4.75% 16.32% 13.37%
5 1.49% 2.16% 2.59%
6 1 74%
1.74% 9 11%
9.11% 6 95%
6.95%
7 0.53% 2.21% 2.74%
8 1.02% 4.83% 5.67%
mean±std 1.5%±1% 5.5%±5% 5.3%±3.6%

V20 = m × VPTV 4 D + b r2= 0.88 r2= 0.84

DEPT OF RADIATION ONCOLOGY


Result (3): Whole body dose
• Cyberknife:
y Total MU 25,000
, ~ 50,000
,
• Linac: Total MU 10,000 ~ 15,000

Cover PTV Cover 60~80% PTV dimension

DEPT OF RADIATION ONCOLOGY


Result (3): Whole body dose
• The absolute risk of both modalities are minimal.
• CyberKnife risk was higher due to the greater
number of MU’s.

CK risk / IMRT risk CK risk / Hypo IMRT risk


Bellon M, Followill D, Ibbott G, et al. Risk of Secondary Fatal Malignancies From
Cyberknife Radiosurgery. Med Phys 2008:35:2983–2983. (A joint oint Study by
DEPT OF RADIATION ONCOLOGY UTSW and RPC, MD Anderson)
Anderson)
Some Practical Consideration
Cyberknife Linac

Treatment Planning • Inverse Planning. • Beam can come through


• No beam come through posterior of patient
posterior of patient • Beam angle limited by table and
gantry collision

Tumor Localization • Few X-Ray images • CBCT Required

Respiratory Control • Need Fiducial (Synchrony) • Larger target area


• Non Fiducial tracking (X- • Abdominal compression
sight Lung tracking).
tracking)

Dose Delivery • Robert moving time • Less MU


• o e MU
More U • djust ttreatment
Adjust eat e t couch
couc angle
a ge

DEPT OF RADIATION ONCOLOGY


Conclusion
• No difference in dose coverage.
• Cyberknife is heterogeneous dose to GTV.
• All lung dose within constrains
constrains.
• No difference to lung in high dose region.
• Lung dose depends on tumor location in low dose
region.

DEPT OF RADIATION ONCOLOGY


Thank you!

DEPT OF RADIATION ONCOLOGY