treatment of multiple metastases
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Treatment of Multiple Metastases Steven Chmura, M.D., Ph.D. - PowerPoint PPT Presentation

Aug 06, 2023 •204 likes •1.57k views

A Trial Introduction to NRG-BR001: A Phase 1 Study of SBRT for the Treatment of Multiple Metastases Steven Chmura, M.D., Ph.D. Principal Investigator The University of Chicago NRG BR001: Talk Outline 1. Hypothesis & trial design 2.

  1. NRG BR001: Treatment planning guidelines • 3DCRT: – 7-13 static beams with zero-margin block-to-PTV margin – Rx isodose line = 60-90% (generally 80-90%) • VMAT: – Dynamic conformal arcs (>340 o ) • 3DCRT/IMRT/VMAT: – Hot spots within target (*) – Rx isodose volume/PTV volume = 1.2-1.5 – 50% isodose per Table 6-4 – Dose at 2cm from PTV per Table 6-4 * = indicates required planning goals

  2. NRG BR001: Dose Conformality for Single Target per RTOG 0813

  3. NRG BR001: Planning Priorities • 6.4.4 Planning Priorities • Every attempt should be made to successfully satisfy all of the planning goals and OAR criteria without deviation. In some circumstances, it may not be possible to meet all the ideal criteria leading to plans with an acceptable deviation. Thus, suggested priority of planning goals in order of importance is: 1. Respect spinal cord, cauda equina, sacral plexus and brachial plexus dose constraints. Meet dose “compactness” constraints including the prescription isodose surface 2. coverage, high dose spillage (location and volume), and intermediate dose spillage (D2cm, and R50%) as these define the “essence” of SBRT. Dose compactness should be assessed for plans based on treatment dose for a single lesion at a time. 3. Meet critical structure constraints other than those listed in 1. The OAR constraints are last in priority (except for nervous system tolerance), because they are the least validated. The “essence” of a stereotactic plan is captured mostly in the dose compactness criteria, thereby justifying their higher priority. As an example in a case where not all goals can be met, it would be suggested to meet dose compactness goals without deviation even at the expense of a non-spinal cord normal tissue having acceptable deviation. Unacceptable deviations should be avoided in all cases. 4. In cases where PTV coverage cannot be achieved while avoiding unacceptable deviations to OAR, coverage of a section of PTV including or immediately adjacent to the OAR may be as low as 70% of the prescription dose ONLY in this situation (see Section 6.5.4).

  4. NRG BR001: OAR constraints

  5. NRG BR001: Compliance Criteria

  6. Benchmark Planning

  7. BR001 Benchmark Case: Bilateral Adrenal Metastases Metastases Overlap with Parallel Organs RT GTV & PTV: LT GTV & PTV Overlap with liver

  8. BR001 Benchmark Case: Bilateral Adrenal Metastases Metastases Overlap with Parallel Organs LT GTV & PTV: Overlap with Kidney RT GTV & PTV

  9. BR001 Benchmark Case: Bilateral Adrenal Metastases Metastasis Overlap with Serial Organ LT GTV & PTV: Overlap with Stomach

  10. NRG BR001: FAQ

  11. NRG BR001: FAQ • Can my institution plan the benchmark with a single isocenter even though my institution has not yet credentialed to deliver treatment to 2 metastases using a single isocenter? – Yes • What should I do if an OAR is not in the structure set? – Contour it if you would like to use it for planning • What QA measurements are required? – None • Should the benchmark plan be reviewed by our physician? – Absolutely! To ensure it’s clinically acceptable

  12. NRG BR001: FAQ • If the plan is intended to treat both lesions simultaneously on the same day, am I required to submit separate dose grids for each lesion? – No (e.g., single VMAT plan) • For an IMRT/VMATplan, is a normalization of 60-90% required? – No, but ensure conformality is high • How should the conformality of the plan be assessed? – See Table 6-4 – 80% isodose should break up between 2 lesions

  13. NRG BR001: FAQ • I cannot meet the PTV coverage requirements while also meeting all the OAR constraints in Table 6-6. How should these competing constraints be balanced? – BR001 provides guidance on the “planning priorities” ( S ECTION 6.4.5): 1. Spinal dose constraints, as assessed on the composite dose map, must always be met. 2. PTV coverage may not fall below 70% of the 45 Gy prescription dose in regions overlapping with OAR. 3. No dose >47.25Gy may exist outside PTV. In addition, no dose >47.25Gy may exist in PTV volumes that overlap directly with OAR (e.g., Liver, Kidney_L, Stomach, Bowel). See S ECTIONS 6.4.3 & 6.5.4. – It is left to the discretion of the institution as to whether they will prioritize PTV coverage over OAR (e.g., stomach) constraints.

  14. NRG BR001: Benchmark Evaluation • How will the benchmark be evaluated? – Dose Volume Analysis (DVA) will be used to tabulate data – Composite dose will be used to evaluate all OAR constraints including 105% hotspot location – If each metastasis is planned for treatment on separate days, individual dose maps will be evaluated for PTV coverage

  15. NRG BR001: Dose Volume Analysis (DVA) for Benchmark Evaluation

  16. Benchmark Examples & Reviews

  17. NRG BR001: Benchmark Case 10 120% = 54 Gy 50% 110% = 49.5 Gy 105% = 47.25 Gy 70% 100% = 45 Gy 95% = 42.75 Gy 80% 90% = 40.5 Gy 80% = 36 Gy 95% 70% = 31.5 Gy 100% 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  18. NRG BR001: Benchmark Case 10 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy D2cm = Max Dose at 2cm from PTV > 90% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  19. NRG BR001: Benchmark Case 10 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 50% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  20. NRG BR001: Benchmark Case 10 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 50% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  21. NRG BR001: Benchmark Case 10 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 50% 100% = 45 Gy overlap 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  22. NRG BR001: Benchmark Case 10 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  23. NRG BR001: Benchmark Case 1 2 Isocenter Plan passed on 2 nd Try. Passed on 2 nd Try. Passed on 2 nd Try.

  24. NRG BR001: Benchmark Case 1 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 2 nd Try. 2 isocenters: passed on 2 nd try.

  25. NRG BR001: Benchmark Case 1 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy 2 isocenters: passed on 2 nd try.

  26. NRG BR001: Benchmark Case 1 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy 2 isocenters: passed on 2 nd try.

  27. NRG BR001: Benchmark Case 1 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy 2 isocenters: passed on 2 nd try.

  28. NRG BR001: Benchmark Case 1 120% = 54 Gy D2cm = Max Dose at 2cm from PTV > 70% 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy 2 isocenters: passed on 2 nd try.

  29. NRG BR001: Benchmark Case 15 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  30. NRG BR001: Benchmark Case 15 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  31. NRG BR001: Benchmark Case 15 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy Priority = PTV 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  32. NRG BR001: Benchmark Case 6 120% = 54 Gy 110% = 49.5 Gy Priority = PTV 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  33. NRG BR001: Benchmark Case 3 120% = 54 Gy 110% = 49.5 Gy Priority = Stomach 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  34. NRG BR001: Benchmark Case 5 120% = 54 Gy 110% = 49.5 Gy Priority = Stomach 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try using VMAT.

  35. NRG BR001: Benchmark Case 12 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 90% connecting 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 2nd try using VMAT.

  36. NRG BR001: Benchmark Case 11 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 100% connecting 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Met DVA criteria but did not pass.

  37. NRG BR001: Benchmark Case 19 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy 95% connecting 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Met DVA criteria but did not pass.

  38. NRG BR001: Benchmark Case 17 CyberKnife 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy D2cm = Max Dose at 2cm from PTV > 85% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy 95% of right PTV receives 48.6Gy  Unacceptable Deviation (< 42.5Gy or > 45.5Gy )

  39. NRG BR001: Benchmark Case 20 CyberKnife 120% = 54 Gy 110% = 49.5 Gy 105% = 47.25 Gy D2cm = Max Dose at 2cm from PTV = 80% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  40. NRG BR001: Benchmark Case 20 CyberKnife 120% = 54 Gy > 90% 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  41. NRG BR001: Benchmark Case 20 CyberKnife 120% = 54 Gy > 80% 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Did not pass.

  42. NRG BR001: Benchmark Case 21 120% = 54 Gy CyberKnife 110% = 49.5 Gy 105% = 47.25 Gy D2cm = Max Dose at 2cm from PTV = 79% 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try.

  43. NRG BR001: Benchmark Case 21 120% = 54 Gy CyberKnife > 95% 110% = 49.5 Gy 105% = 47.25 Gy 100% = 45 Gy 95% = 42.75 Gy 90% = 40.5 Gy 80% = 36 Gy 70% = 31.5 Gy 50% = 22.5 Gy 25% = 11.25 Gy Passed on 1 st try.

  44. NRG BR001: Benchmark Statistics • As of Jan 28, 2015: – Benchmarks submitted = 22 – Benchmarks not passing but not yet re-submitted = 7 – Benchmarks passing = 15 • At 1 st attempt = 8 • At 2 nd attempt = 5 • At 3 rd attempt = 2 • Sites completed all credentialing = 9! • Satellites are required to submit benchmark.

  45. NRG BR001: Benchmark Statistics • Treatment strategy: – 1/15 treated with 2 separate plans to each lesion – 1/15 delivered with CyberKnife • Planning priorities: – 4/15 spared stomach – 11/15 treated PTV

  46. NRG BR001: Benchmark Statistics • PTV volume (LT + RT) = 103 cc • 95% dose volume = 128 cc (102-175) • 80% dose volume = 211 cc (164-346) • 70% dose volume = 279 cc (226-476) • 50% dose volume = 519 cc (416-872) • 105% dose volume = 39 cc (0-131) • Max dose at 2cm = 71% (58-88%)

  47. IGRT Credentialing Review

  48. NRG BR001: IGRT Credentialing

  49. NRG BR001: IGRT Credentialing

  50. NRG BR001: IGRT Credentialing • Purpose: – To assess whether positioning with image-guidance will ensure accurate PTV coverage • How is this accomplished? – Assess description of IGRT workflow including threshold for correction of translations & rotations – Assess image quality (technique, FOV) – Assess final treatment position relative to PTV margin required for protocol

  51. NRG BR001: IGRT Credentialing • Potential issues encountered with 3D registration: – Table movement prior to acquiring CBCT – Inter-observer variation

  52. NRG BR001: IGRT Credentialing • Recommended data for 2D IGRT: – 2D screenshots in addition to 2D DICOM images: • Reticule or scale • PTV contours • OAR contours (e.g., lung, spine) – 2D OBI screenshots at final treatment position helpful • Recommended data for 3D IGRT: – Screenshots of in-house registration between CBCT & planning CT • Reticule or scale • 3D blending/subtraction

  53. NRG BR001: 3D Spine IGRT Case 3 BrainLab ExacTrac

  54. NRG BR001: 3D Spine IGRT Case 3 OBI kV

  55. NRG BR001: 3D Spine IGRT Case 3 OBI kV

  56. NRG BR001: 3D Spine IGRT Case 3

  57. NRG BR001: 3D Spine IGRT Case 9

  58. NRG BR001: 3D Spine IGRT Case 9

  59. NRG BR001: 3D Spine IGRT Case 9

  60. NRG BR001: 3D Spine IGRT Case 9 Axis X Y Z Institution Shifts -8.0 1.0 2.0 Reviewer Shifts -5.6 1.5 1.0 Difference -2.4 0.5 1.0

  61. NRG BR001: 3D Spine IGRT Case 9 Axis X (mm) Y (mm) Z (mm) Institution’s Shifts -8.0 1.0 2.0 Reviewer’s Shifts -5.6 1.5 1.0 Difference -2.4 0.5 1.0 Rotational Differences < 2 degrees

  62. NRG BR001: 3D Spine IGRT Case 9

  63. NRG BR001: 3D Lung IGRT Case 9

  64. NRG BR001: 3D Lung IGRT Case 9

  65. NRG BR001: 3D Lung IGRT Case 9

  66. NRG BR001: 3D Lung IGRT Case 9

  67. NRG BR001: 3D Lung IGRT Case 9 Axis X (mm) Y (mm) Z (mm) Institution’s Shifts 2.3 -4.6 6.5 Reviewer’s Shifts 1.6 0.1 -5.2 Difference 0.7 -4.7 -1.3 Rotational Differences < 2 degrees

  68. NRG BR001: 3D Lung IGRT Case 9

  69. Available Resources & Guidelines

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