Transcript Nodulo polmonare periferico : Cyberknife

Nodulo polmonare periferico : Cyberknife
RADIOTERAPIA
ISTITUTO FIORENTINO CURA
E ASSISTENZA
•
Staff Medico:
Dott.
I.BONUCCI
Dott.ssa S. CIPRESSI
•
Staff T.S.R.M.:
M. TEMPOBONO
S.
PAZZAGLINI
•
Staff
INFERMIERI:
O. OLIVIERI
N. BELLOSI
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Staff Fisico Sanitario: V. LONARDO
Dott.ssa L. MASI
G. PARENTI
Dott.ssa R. DORO
A. FRANCHI
Dott. I.PERUZZI
M. CIALDAI
Master Universitario di II Livello in Pneumologia Interventistica
•
Staff
AMMINSTRATIVE:
P. TAFI
S.PARIGI
2014
1990
A compact 1000 MU/min 6MV X-band linear accelerator
capable of being positioned in virtually any direction by a
high precision robotic manipulator with repeatable submillimeter accuracy
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
The location of these nodes is currently
fixed in space, with some range over which
the node sphere can be moved to
accommodate targets that are not located
at the center of the targeting and
imaging volume.
Master Universitario di II Livello in Pneumologia Interventistica
Cyberknife could be employed to treat :
 brain ,
 spine and bones,
 lung ,
 prostate ,
 liver ,
 head and neck
 Benign lesions
 and other extracranial sites
 3D images are transferred to the MultiPlan® TPS via a dedicated database server;
 from CT plan a 3D patient model is generated and within which treatment beams are
positioned;
 The robot manipulator places the position of the nominal radiation source of the linear
accelerator at specific points in space called “nodes,” roughly distributed evenly on the surface
of a sphere that is centered at the center of the x-ray targeting system
 Each node can originate a number
of treatment beams (currently up to 12)
Master Universitario di II Livello in Pneumologia Interventistica
Cyberknife evaluation:
 Ineligible for surgery:
• lacked adequate respitatory reserve,
•cardiac dysfuction or chronic heart disease;
• pulmonary hypertension;
• diabets mellitus with severe end-organ demage;
• vascular disease;
•Severe cerebral disease
• general frailty
Master Universitario di II Livello in Pneumologia Interventistica
Cyberknife evaluation:
Unresectable non small cell lung carcinoma (T1-T2);
 Metastatic disease:
• breast
•colorectal carcinoma;
•Soft tissue sarcoma;
• melanoma;
• renal cell carcinoma;
• lymphoma…
19 pazie:nts
11 non small cell lung cancer stage T1-T2
8 lung met
Master Universitario di II Livello in Pneumologia Interventistica
Cyberknife evaluation:
Journal of Hematology & Oncology
Master Universitario di II Livello in Pneumologia Interventistica
Treatment Delivery System
 6D Skull Tracking: This method can be used for intracranial targets
as well as head and neck targets that are considered to be fixed
relative to the skull.
 Xsight® Spine Tracking: This method can be used for targets
located anywhere in the spine, or targets located near the spine and
considered to be fixed relative to it.
 Xsight Lung Tracking: This method can be used to track tumors
located within the lung without the use of implanted fiducial markers.
 Fiducial Marker Tracking: This method can be used for soft tissue
targets that are not fixed relative to the skull or spine (e.g., prostate,
pancreas, liver), including lung tumors for which the Xsight lung
tracking method is unsuitable.
 Synchrony Respiratory Motion Tracking System: The Synchrony
Respiratory Tracking System provides real-time tracking for tumors
that move with respiration.
Master Universitario di II Livello in Pneumologia Interventistica
 Xsight® Spine Tracking: This method can be used for targets
located anywhere in the spine, or targets located near the spine and
considered to be fixed relative to it.
Limitations :
1. Does not track the movement of the tumor during tretament;
2. Requires a lager treatmente volume;
Master Universitario di II Livello in Pneumologia Interventistica
 Fiducial Marker Tracking: This method can be used for soft tissue
targets that are not fixed relative to the skull or spine including lung
tumors for which the Xsight lung tracking method is unsuitable.
Limitations :
1. Risk of pneumothorax after percutaneous positioning;
2. Fiducial marker misplacement and/or migration;
3. Treatment delays.
Master Universitario di II Livello in Pneumologia Interventistica
 Synchrony Respiratory Motion Tracking System: The Synchrony
Respiratory Tracking System provides real-time tracking for tumors
that move with respiration.
Limitations :
1. Risk of pneumothorax after percutaneous positioning;
2. Fiducial marker misplacement and/or migration;
3. Treatment delays.
Master Universitario di II Livello in Pneumologia Interventistica
1.Fiducial impiantati prima del trattamento
2. Reperi ottici (LED)su un giubbotto
3. Modello:Creazione prima e aggiornamento durante
l’erogazione del trattamento.
Il sistema di imaging acquisisce le
posizioni dei fiducial in modo discreto
I reperi ottici esterni sono monitorati in tempo
reale dal sistema di camere
Master Universitario di II Livello in Pneumologia Interventistica
pneumothorax
Master Universitario di II Livello in Pneumologia Interventistica
migration
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
 Xsight Lung Tracking: This method can be used to track tumors
located within the lung without the use of implanted fiducial markers.
Overcome the
others tracking
limitations
Limitations :
1. Requires a adequate tumor visualization by the system;
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
Monitoraggio continuo
reperi esterni (LED)
Master Universitario di II Livello in Pneumologia Interventistica
Prima del trattamento si crea un modello di correlazione dinamico tra segnale
esterno e reperi interni.
Durante il trattamento il processo continua. Il modello viene aggiornato basandosi
sul movimento respiratorio del paziente del momento. Il modello viene passato al
robot per permettere il tracking in tempo reale del tumore.
Il sistema di imaging acquisisce le posizioni dei
o del target in modo discreto
Si crea un modello che correla la
posizione interna del tumore ai reperi
esterni sul torace
Posizione tumore
spostamento
I reperi ottici esterni sono monitorati in
tempo reale dal sistema di camere
tempo
Master Universitario di II Livello in Pneumologia Interventistica
Posizione Reperi esterni
1. Il modello di correlazione è creato separatamente per ogni Marker.
2. Ogni modello fornisce una stima della posizione del target. Le singole posizioni
stimate per ogni repere sono mediate per ottenere la stima finale della posizione del
target, in tempo reale.
3. La posizione stimata non viene inviata direttamente al robot: latenze di
comunicazione e inerzia del robot creerebbero ritardi nella risposta (~ 120 ms).
4. Un algoritmo dedicato “predictor”, permette di compensare i ritardi del sistema: si usa
in modo adattivo la storia dei movimenti del target.
Universitarioèdiulteriormente
II Livello in Pneumologia
Interventistica
5. Master
Il movimento
filtrato
con smoothing prima di passare al robot.
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
For patient 1: (adequate test)
1/4 orthogonal vectors projected on the
vertebrae and 0/4 on the mediastinum.
For patient 2: (inadequate test)
4/4 vectors projected on the mediastinum
and 2/4 vectors projected on the vertebral
column
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
Larger tumor size (>3.5 cm)
and
Higher tumor density are
predictive of adequate
detection
Master Universitario di II Livello in Pneumologia Interventistica
Master Universitario di II Livello in Pneumologia Interventistica
 Contouring:
Planning CT 1.25 mm
Master Universitario di II Livello in Pneumologia Interventistica
 GTV: gross tumor volume
 PTV: GTV + 2-5 mm margins
GTV
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PTV
Master Universitario di II Livello in Pneumologia Interventistica
ITV
Master Universitario di II Livello in Pneumologia Interventistica
DOSE:
 26 Gy in 1# at 70% isodose;
 36-60 Gy in 3# at 70-85 %isodose
Master Universitario di II Livello in Pneumologia Interventistica
Lung:
V15 < 15 Gy
Master Universitario di II Livello in Pneumologia Interventistica
Excessive Toxicity When Treating Central Tumors
Patients treated for
tumors in the
peripheral lung had
2-year freedom from
severe toxicity of 83%
compared with only
54% for patients with
central tumors
Master Universitario di II Livello in Pneumologia Interventistica
Toxicity
 G1-G2:
 fatigue
 musculoskeletal discomfort
 radiation pneumonitis
 G3:
pneumonias
pleural effusions
pericardial effusion
hemoptysis
apnea
Master Universitario di II Livello in Pneumologia Interventistica
tumor location in the chest
T stage
GTV-PTV
Histology
Laterality
pulmonary function tests
Age
cardiac versus pulmonary
 cause of inoperability,
oxygen dependence
performance status
ongoing smoking
Cancer Management and Research 2012
Master Universitario di II Livello in Pneumologia Interventistica
Response
CR
No visible gross tumor
PR
≥30% decrease
SD
Neither sufficient shrinkage for PR nor sufficient
increse for PD
PD
As more than 20% increase of GTV
Master Universitario di II Livello in Pneumologia Interventistica
Conclusion
 Relatively small peripheral lung nodules may be radically
treated
 Encourage early local control from literature [92%]
 The delivery trackings allow for highly conformal dose
distributions
Accettable toxicity
Ideal dose and fractionation
Master Universitario di II Livello in Pneumologia Interventistica
Thanks for your
attention!!!