From 2D to 3D Conformal Radiation Therapy (3D-CRT) and IMRT: The AC - PowerPoint PPT Presentation

From 2D to 3D Conformal Radiation Therapy (3D-CRT) and IMRT: The AC Camargo Hospital experience Paulo Eduardo Novaes MD, PhD PhD Paulo Eduardo Novaes MD, Hospital AC Camargo – – São Paulo São Paulo - - Brasil Brasil Hospital AC Camargo

Hospital AC Camargo – São Paulo – Brasil www.accamargo.org.br

Hospital AC Camargo � Reference Cancer Center - Brazil � Founded: 1953 - Beds: 250 - Surgical rooms: 30 � Actuation: Assistance, learn and research � Multidisciplinary approach – Integrated Services � Radiation Therapy Department: 2000 patients/year � Linacs (4), Radiosurgery (Brain-lab M3), IORT (surgical room) 3D- TPS (ARIA) – 3D-CRT and IMRT � HDRB (Ir 192 ), Prostate Brachy (I 125 ), Ophtalmic Brachy (I 125 /Ru 103 )

To deliver deliver effective effective dose to dose to the the tumor tumor To sparring the the neighbouring neighbouring normal normal tissues tissues sparring 1895 Radio-biological knowledge Improve clinical care Colaborative Protocols Information network 2009 Technological advances

2D � Planning Planning based based on on clinical clinical exam exam and and bone bone � landmarks landmarks � Conventional Conventional simulation simulation – – x x- -rays rays films films � Normal organs organs and and crictical crictical structures structures � Normal � visualization: : dificult dificult visualization � Field Field arrangement arrangement: : simple simple - - co co- -planar planar � � Dose Dose distribution distribution studies studies: : limited limited - - points points �

Lateral Cervix cancer - EBRT AP

3D � Planning Planning besed besed on on tumor tumor and and normal normal tissues tissues � visualization visualization � CT CT- -simulation simulation: CT/MRI/PET : CT/MRI/PET � Dose deliver deliver: : improved improved – – image image fusion fusion � Dose � � Field Field arrangement arrangement: : complex complex – – multiple multiple - - non non � coplanar fields fields coplanar � Dose Dose distribution distribution: DVH : DVH – – precise (volume) precise (volume) �

From 2D to 3D Steps � New concepts: GTV, CTV, PTV, OAR � Delineation rules and dose-constraints � DVH: familiarization – interpretation � From SSD to Isocenter techniques � To improve immobilization systems and lead blocks construction – multi-leaf collimators � Permanent staff trainning - QA program development � Technical maintenance � Collaborative programs and protocols – expert visits

3D-Planning CT Simulation

Image Fusion – CT/MRI/Pet scan

3D-CRT/year 968 1000 900 800 710 700 627 600 500 450 400 317 305 300 227 200 100 0 2002 2003 2004 2005 2006 2007 2008 Radiation Therapy Department Hospital AC Camargo – São Paulo

Intensity Modulated Radiation Therapy IMRT IMRT

From 3D to IMRT Steps � New concept: Inverse treatment planning � Delineation rules and dose-constraints: similar � DVH: familiarization – interpretation � To improve immobilization systems and multi-leaf collimators � Permanent staff trainning – Technical maintenance � QA program development –Photon fluence maps � Collaborative programs and protocols – expert visits

Multi-leaf collimators

3D vs. IMRT: Maps of Intensity Maps of Intensity 3D vs. IMRT: Computer Film

Rabdomyosarcoma of the tongue Child 10 10 years years old old Child

Isocenter Isocenter

IMRT fields fields IMRT

Gy (95%) (95%) 47.5Gy Isodose 47.5 Isodose

IMRT Comparison Comparison 3D

Comparison Comparison

DVH IMRT DVH IMRT

Isodose Mandible Mandible Isodose

IMRT/year IMRT - HOSPITAL A. C. CAMARGO 300 290 280 270 244 260 250 240 230 199 220 210 200 190 NUMBER 180 170 160 150 140 130 120 110 100 90 64 80 70 44 60 50 40 30 6 20 10 0 2004 2005 2006 2007 2008

IMRT sites IMRT - ANATOMIC SITES (INCLUDING THREE MONTHS 2009) 300 280 250 200 168 150 150 100 50 33 0 H&N CNS PRT OTHERS

2D and 3D + IMRT/year 2500 2000 1500 3D + IMRT 2D Total 1000 500 0 2003 2004 2005 2006 2007 2008

3D-CRT and IMRT � Conclusions � Natural radiation therapy evolution � Permanent improvement � Clinical experience progressive � Collaborative studies - Definitive results � New horizon on radiation therapy � Atractive - Risks and Benefits � New questions ....

Real gain ?