Morphology Guided Adaptation

1. Adapt to the Future - Liverpool Hospital, Nov 18 2011 Morphology Guided Adaptation

2. Structure • What we thought about • How we investigated • What we have measured • What has been learnt along the way

3. What we thought about What were the problems with fields? • WYSINWYG • what you see is NOT what you get • rectifiable inaccuracies of >40% • all geographic misses when you can see • IMAGING • improved technology changes treatment approaches • changes professional knowledge levels • changes professional competence levels • II simulation > CT simulation • FIELDS are not “conventional” any more! • IMRT • Used for >10 years • Technology in every Australian centre for >5 years • Who does randomised trials of new technology?

4. What we thought about We have several adaptive technologies: • IMRT • adapting dose to match volumes/contours • IGRT • adapting dose to reduce movement effects • what do we call adapting dose to match  • changing shape of volumes and  • changing shape of contours?

5. What we thought about • What name should be used? • "adaptive" is a generic term • IGRT adapts isocentre to the present position of the patient • IMRT adapts dose to the spatial arrangement of contours and volumes • what term to use when adapting a radiotherapy plan to the changes in disease and anatomical morphology? the term we have used is MORPHOLOGY GUIDED RADIOTHERAPY “MGRT”

6. What we thought about • The big picture • IMRT is undertaken by RT-dosimetrists • match a radiation dose line to a volume outline • NOT a medical decision (cf medical approval) • requires training in radiation physics and planning • IGRT is undertaken by RTs • match fiducial/bony/soft tissue landmarks • NOT a medical decision • requires training in anatomy • MGRT is undertaken by ROs • reproduce yesterday's clinical decisions on today’s (altered) volumes and contours • ALL medical decisions • requires training in cancer biology and disease processes

7. What we thought about The Old Magic The New Magic

8. How we investigated • Wollongong Re-scan Project • Dr FarhannahAly • H&N • Non-surgical management of primary & necks • IMRT, >98% of PTV covered by 95% isodose • Weekly • Simulation • [RT(S)] Rescan > Fuse • [RO] Re-volume/Re-contour • [RT(D)] Transfer old IMRT fields, recalculate • [RO] Assess • If PTV coverage >95% leave • If PTV coverage <95% [RT(D)] re-plan • [D] Dietary measures

9. How we investigated • 10 patients • >70 CT scans

10. What we have measured • Systematic measurements • Isodose coverage • PTV6000 • PTV7000 • CTV changes • Parotid • Absolute changes • Relative changes • Dose deposition changes • COM position changes

11. Changes between Simulation & Day 1 Changes can be rapid and large

13. What we have measured • Systematic measurements • Isodose coverage • PTV6000 – significant changes • PTV7000 – significant changes • CTV changes • Parotid • Absolute changes • Relative changes • Dose deposition changes • COM position changes

14. Changes in clinical volumes during treatment (% change)

15. What we have measured • Systematic measurements • Isodose coverage • PTV6000 – significant changes • PTV7000 – significant changes • CTV changes – get smaller • Parotid • Absolute changes • Relative changes • Dose deposition changes • COM position changes

19. What we have measured • Systematic measurements • Isodose coverage • PTV6000 – significant changes • PTV7000 – significant changes • CTV changes – get smaller • Parotid • Absolute changes - shrinks • Relative changes - shrinks • Dose deposition changes • COM position changes

22. What we have measured • Systematic measurements • Isodose coverage • PTV6000 – significant changes • PTV7000 – significant changes • CTV changes – get smaller • Parotid • Absolute changes - shrinks • Relative changes - shrinks • Dose deposition changes – more dose (?) • COM position changes

25. What we have measured • Systematic measurements • Isodose coverage • PTV6000 – significant changes • PTV7000 – significant changes • CTV changes – get smaller • Parotid • Absolute changes - shrinks • Relative changes - shrinks • Dose deposition changes – more dose (?) • COM position changes – slightly more medial

26. What we have measured • Diet • PG-SGA • Assessment • Score • Habitus Measures • Neck/Chest/Abdominal circumference • ‘Isocentre’ fat • Weight

27. PG-SGA • Category • Global Assessment • Score • Weight Loss • Condition • Metabolic Stress • Physical Examination • Fat stores • Muscle status • Fluid status

28. Weight Loss during treatment (kg) Nutritional Status during treatment PG-SGA score Weight (kg) Weeks of treatment Weeks of treatment

29. What we have measured • Diet • PG-SGA • Assessment • Score – worsening dietary intake and condition • Weight - ~10% weight loss • Habitus Measures • Neck/Chest/Abdominal circumference • ‘Isocentre’ fat

31. What we have measured • Diet • PG-SGA • Assessment • Score – worsening dietary intake and condition • Weight - ~10% weight loss • Habitus Measures • Neck/Chest/Abdominal circumference - similar • ‘Isocentre’ fat – less isocentre fat

32. What we have learnt • asymmetric CTVs change • Nodes get smaller and move

33. What we have learnt • WYPlanInotWYTreat • EARLY Changes are marked and variable • LATE Changes are few • TEAM WORK • 24 hour turnaround on IMRT plan • More coordination than we are used to

34. What we have learnt • Isocentre placement • Where is the best place? • Improved planning • Rapidity • Consistency • Iterative DVH use • Problem of the dose escalated parotids

35. Parotid V26 doses Adaptive Plan Original Plan