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PD-0156 STEREOTACTIC BODY RADIOTHERAPY USING VOLUMETRIC MODULATED ARC THERAPY IN LUNG METASTATIC PATIENTS
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DEBATE: THIS HOUSE BELIEVES THAT DAILY VERIFICATION AND IMAGE ANALYSIS IS SOLELY THE RESPONSIBILITY OF THE RADIATION ONCOLOGIST SP-0154 FOR THE MOTION J. Kuipers1 1 Radiotherapy Centre West, Radiotherapy, The Hague, The Netherlands Imaging of patients whilst on the radiotherapy treatment table has gone from manually verifying the portal film with the x-ray from the simulator through position correction based on electronic portal images to Conebeam-CT and computer-aided verification and online adaptive radiotherapy. I state that because of these developments and changes in the role of imaging in adaptive radiotherapy the radiation oncologist (RO) is solely responsible for the verification and image analysis. To come to this statement I look at the shifting role of imaging caused by the advancing technology over the past ten years. I am comparing that to the definition of what the responsibilities are of the RO and radiation therapist (RTT). These responsibilities are defined by the (intention of) their respective education, work experience and legal boundaries. The role of imaging went from verification, if a dose was given at the prior appointed place, to a means by which gets decided what treatment a patient gets that day. At the same time doses are getting higher, margins are getting smaller. The main responsibility of the RTT should be that the patient gets what the doctor ordered. While the RO gets to decide what treatment (i.e. what doses at what areas) is given. The role of imaging chanced, responsibilities of RO and RTT stayed the same. It becomes obvious that the RTT steps far into RO territory if the RTTwould be responsible for the verification and image analysis with adaptive radiotherapy. Radiation oncologists should first have a full insight in the consequences through (years of) experience and the further development of soft- and hardware. Only then can they decide if and how that role can be (partially) handed over to the RTT. SP-0155 AGAINST THE MOTION A. Osztavics1 1 Department of Radiotherapy, Med. Univ. Vienna / AKH Vienna, Vienna, Austria Over the past decade, fundamental advances in image-guided radiation therapy (IGRT) have been made in clinical practice. Imaging technologies that direct and confirm beam accuracy at the time of radiotherapy delivery have been intensively investigated and implemented. As advanced radiotherapy treatment approaches for delivering conformal dose to the tumour while sparing the normal tissues have been developed, the use of image guidance for treatment accuracy has become essential. Avoidance of unexpected under- or overdosing during treatment is a key objective for IGRT. To archive this aim, image guidance devices in use include kV on-board imagers and kV/MV cone-beam CT systems. In addition other systems that use non ionizing sources, such as ultrasound, optical systems, and electromagnetic devices have been introduced to monitor or track patient and/or tumour movements during treatment. These devices have been designed specifically for monitoring and/or controlling respiratory motion. IGRT is defined as frequent imaging in the treatment room that allows treatment decisions to be made on the basis of daily verification. The implementation and integration of these devices continue to carry practical challenges, which emphasize the need for further development of the technologies and their clinical applications based on tailored education path. The question posed is who should take the main responsibility in IGRT? Only the Radiation oncologist (RO), the Radiation Therapist (RTT) or both? IGRT is implemented in the final part of the workflow in each modern radiotherapy department. So if this house believes that daily verification and image analysis is solely the responsibility of the RO, should the RO have an active role at the virtual simulator, fluoroscopy, MRI, and simple X- rays? If the RO´s responsibility is solely the patient, (this happens around the world) which other professionals can the RO delegate for some important parts in the workflow? What will the scenario in future be in health care systems across Europe? Is it possible to maintain the current quality level with all the
ESTRO 31
pending external factors (financial crises, new therapy concepts, understaffed departments, new technical equipment/technologies and the increasing knowledge expectation from the patients and their relatives? How can this issue be handled in radiotherapy in a safe and accurate manner? At present, there is no single country with sufficient economic resources to allocate adequate time from the RO´s schedule for image verification at the accelerator in addition to their other duties i.e. planning, follow up, patient education and research. Currently these challenges are managed because IGRT is only used for a subset of patients and not on a daily basis. With the availability of the first results from IGRT studies, we recognize the impact of IGRT in the TCP and survival rate necessitating the implementation and use of this equipment in a proper way. We also have new editions of the Core Curricula for RO and RTT from ESTRO available. RTTs, are already trained and educated to operate CT, MRI and PET units, run simulator and X-rays facilities, handle TPS and of accelerators which make them more than competent to handle daily image verification and analysis for correct patient alignment. The important and key issue is the need to adapt to the demands and expectations of modern day radiotherapy and the RTTs have to be allowed to maximise their skills and this can be achieved with well educated RTT´s with excellent patient care skills. Responsibility is a combination of education, competence, experience and legal issues and this should not be exclusively for RO.
POSTER DISCUSSION: 4: LUNG AND STEREOTACTIC PD-0156 STEREOTACTIC BODY RADIOTHERAPY USING VOLUMETRIC MODULATED ARC THERAPY IN LUNG METASTATIC PATIENTS P. Navarria1, A.M. Ascolese1, E. Clerici1, S. Castiglioni1, F. Alongi1, A. Tozzi1, S. Pentimalli1, S. Arcangeli1, P. Mancosu1, M. Scorsetti1 1 Clinico Humanitas Cancer Center, Radiotherapy and Radiosurgery, Rozzano Milano, Italy Purpose/Objective: Data on the use of stereotactic body radiation therapy (SBRT) in oligometastatic patients are emerging and the early results on local control are promising. Aim of this study was to evaluate results and toxicity of SBRT using Volumetric Modulated Arc Therapy(VMAT)- Flattening Filter Free (FFF) mode in lung metastatic patients from different primary tumors. Materials and Methods: One hundred forty-five consecutive patients treated between October 2010 to September 2011 were included. The most common primary cancers were lung and colon-rectal. One hundred sixty-seven SBRT were performed. All patients had oligometastatic disease. Dose prescription was 48 Gy in 4 consecutive fractions for peripheral lesions with maximum diameter < 3 cm, 60 Gy in 6 consecutive fractions for central lesions and 32 Gy in 4 consecutive fractions for lesions with maximum diameter between 3 and 5 cm or in case of multiple lesions in the same lung. Clinical outcome was evaluated by CT scan and CT-PET. The incidence of pneumonitis was graded according to the NCI CTCAE v3.0 scale. Results: Median follow-up was 9 months (range 3-14). Response was recorded in 134/167 lesions (80%). At the last follow up 132/155 of patients (85%) were alive. No pulmonary toxicity of grade 2 or greater was recorded. No chest pain toxicity occurred. Removal of the flattening filter (FF) increased the dose rate. The median beam-on time (BOT) was reduced by 75% passing from about 8 minutes (with FF modality) to 2 minutes (with FFF modality). Conclusions: SBRT is a feasible, safe and effective local treatment option for pulmonary metastases in patients with contraindications to surgery or for palliation of symptomatic pulmonary metastases. VMAT technique improved target coverage while minimizing higher dose to normal tissue with respect to coplanar beam arrangements. Furthermore, the BOT was significantly reduced in FFF modality with a subsequent increase of patient comfort and reduction of intrafraction motion. In our experience SBRT with VMAT-FFF resulted in a good radiological response though a longer follow-up is needed to assess the effective outcome incidence and to select patients with better prognosis. PD-0157 DOSE COVERAGE IN IMAGE GUIDED SBRT FOR NSCLC USING TOMOTHERAPY L. Kerkmeijer1, V. Althof2, A. Minken2, R. Steenberg2, E. Vonk2 1 U.M.C. Utrecht, Radiation Oncology, Utrecht, The Netherlands
DEBATE: THIS HOUSE BELIEVES THAT DAILY VERIFICATION AND IMAGE ANALYSIS IS SOLELY THE RESPONSIBILITY OF THE RADIATION ONCOLOGIST SP-0154 FOR THE MOTION J. Kuipers1 1 Radiotherapy Centre West, Radiotherapy, The Hague, The Netherlands Imaging of patients whilst on the radiotherapy treatment table has gone from manually verifying the portal film with the x-ray from the simulator through position correction based on electronic portal images to Conebeam-CT and computer-aided verification and online adaptive radiotherapy. I state that because of these developments and changes in the role of imaging in adaptive radiotherapy the radiation oncologist (RO) is solely responsible for the verification and image analysis. To come to this statement I look at the shifting role of imaging caused by the advancing technology over the past ten years. I am comparing that to the definition of what the responsibilities are of the RO and radiation therapist (RTT). These responsibilities are defined by the (intention of) their respective education, work experience and legal boundaries. The role of imaging went from verification, if a dose was given at the prior appointed place, to a means by which gets decided what treatment a patient gets that day. At the same time doses are getting higher, margins are getting smaller. The main responsibility of the RTT should be that the patient gets what the doctor ordered. While the RO gets to decide what treatment (i.e. what doses at what areas) is given. The role of imaging chanced, responsibilities of RO and RTT stayed the same. It becomes obvious that the RTT steps far into RO territory if the RTTwould be responsible for the verification and image analysis with adaptive radiotherapy. Radiation oncologists should first have a full insight in the consequences through (years of) experience and the further development of soft- and hardware. Only then can they decide if and how that role can be (partially) handed over to the RTT. SP-0155 AGAINST THE MOTION A. Osztavics1 1 Department of Radiotherapy, Med. Univ. Vienna / AKH Vienna, Vienna, Austria Over the past decade, fundamental advances in image-guided radiation therapy (IGRT) have been made in clinical practice. Imaging technologies that direct and confirm beam accuracy at the time of radiotherapy delivery have been intensively investigated and implemented. As advanced radiotherapy treatment approaches for delivering conformal dose to the tumour while sparing the normal tissues have been developed, the use of image guidance for treatment accuracy has become essential. Avoidance of unexpected under- or overdosing during treatment is a key objective for IGRT. To archive this aim, image guidance devices in use include kV on-board imagers and kV/MV cone-beam CT systems. In addition other systems that use non ionizing sources, such as ultrasound, optical systems, and electromagnetic devices have been introduced to monitor or track patient and/or tumour movements during treatment. These devices have been designed specifically for monitoring and/or controlling respiratory motion. IGRT is defined as frequent imaging in the treatment room that allows treatment decisions to be made on the basis of daily verification. The implementation and integration of these devices continue to carry practical challenges, which emphasize the need for further development of the technologies and their clinical applications based on tailored education path. The question posed is who should take the main responsibility in IGRT? Only the Radiation oncologist (RO), the Radiation Therapist (RTT) or both? IGRT is implemented in the final part of the workflow in each modern radiotherapy department. So if this house believes that daily verification and image analysis is solely the responsibility of the RO, should the RO have an active role at the virtual simulator, fluoroscopy, MRI, and simple X- rays? If the RO´s responsibility is solely the patient, (this happens around the world) which other professionals can the RO delegate for some important parts in the workflow? What will the scenario in future be in health care systems across Europe? Is it possible to maintain the current quality level with all the
ESTRO 31
pending external factors (financial crises, new therapy concepts, understaffed departments, new technical equipment/technologies and the increasing knowledge expectation from the patients and their relatives? How can this issue be handled in radiotherapy in a safe and accurate manner? At present, there is no single country with sufficient economic resources to allocate adequate time from the RO´s schedule for image verification at the accelerator in addition to their other duties i.e. planning, follow up, patient education and research. Currently these challenges are managed because IGRT is only used for a subset of patients and not on a daily basis. With the availability of the first results from IGRT studies, we recognize the impact of IGRT in the TCP and survival rate necessitating the implementation and use of this equipment in a proper way. We also have new editions of the Core Curricula for RO and RTT from ESTRO available. RTTs, are already trained and educated to operate CT, MRI and PET units, run simulator and X-rays facilities, handle TPS and of accelerators which make them more than competent to handle daily image verification and analysis for correct patient alignment. The important and key issue is the need to adapt to the demands and expectations of modern day radiotherapy and the RTTs have to be allowed to maximise their skills and this can be achieved with well educated RTT´s with excellent patient care skills. Responsibility is a combination of education, competence, experience and legal issues and this should not be exclusively for RO.
POSTER DISCUSSION: 4: LUNG AND STEREOTACTIC PD-0156 STEREOTACTIC BODY RADIOTHERAPY USING VOLUMETRIC MODULATED ARC THERAPY IN LUNG METASTATIC PATIENTS P. Navarria1, A.M. Ascolese1, E. Clerici1, S. Castiglioni1, F. Alongi1, A. Tozzi1, S. Pentimalli1, S. Arcangeli1, P. Mancosu1, M. Scorsetti1 1 Clinico Humanitas Cancer Center, Radiotherapy and Radiosurgery, Rozzano Milano, Italy Purpose/Objective: Data on the use of stereotactic body radiation therapy (SBRT) in oligometastatic patients are emerging and the early results on local control are promising. Aim of this study was to evaluate results and toxicity of SBRT using Volumetric Modulated Arc Therapy(VMAT)- Flattening Filter Free (FFF) mode in lung metastatic patients from different primary tumors. Materials and Methods: One hundred forty-five consecutive patients treated between October 2010 to September 2011 were included. The most common primary cancers were lung and colon-rectal. One hundred sixty-seven SBRT were performed. All patients had oligometastatic disease. Dose prescription was 48 Gy in 4 consecutive fractions for peripheral lesions with maximum diameter < 3 cm, 60 Gy in 6 consecutive fractions for central lesions and 32 Gy in 4 consecutive fractions for lesions with maximum diameter between 3 and 5 cm or in case of multiple lesions in the same lung. Clinical outcome was evaluated by CT scan and CT-PET. The incidence of pneumonitis was graded according to the NCI CTCAE v3.0 scale. Results: Median follow-up was 9 months (range 3-14). Response was recorded in 134/167 lesions (80%). At the last follow up 132/155 of patients (85%) were alive. No pulmonary toxicity of grade 2 or greater was recorded. No chest pain toxicity occurred. Removal of the flattening filter (FF) increased the dose rate. The median beam-on time (BOT) was reduced by 75% passing from about 8 minutes (with FF modality) to 2 minutes (with FFF modality). Conclusions: SBRT is a feasible, safe and effective local treatment option for pulmonary metastases in patients with contraindications to surgery or for palliation of symptomatic pulmonary metastases. VMAT technique improved target coverage while minimizing higher dose to normal tissue with respect to coplanar beam arrangements. Furthermore, the BOT was significantly reduced in FFF modality with a subsequent increase of patient comfort and reduction of intrafraction motion. In our experience SBRT with VMAT-FFF resulted in a good radiological response though a longer follow-up is needed to assess the effective outcome incidence and to select patients with better prognosis. PD-0157 DOSE COVERAGE IN IMAGE GUIDED SBRT FOR NSCLC USING TOMOTHERAPY L. Kerkmeijer1, V. Althof2, A. Minken2, R. Steenberg2, E. Vonk2 1 U.M.C. Utrecht, Radiation Oncology, Utrecht, The Netherlands