What should you take away from this presentation?
• A better understanding of how treatment machines can affect:
– Cancer Care Facility
• Radiation Therapists
• Radiation Oncologists
• Medical Physicists
• Dosimetrists
• Patient Satisfaction
11
OHSU’s Latest Treatment Modalities • Varian Trilogy • Tomotherapy • Varian/Novalis
– Brain Lab – Exactrac
• Calypso • Philips CT SIM • Brachytherapy
– HDR – Eye plaques
• Intrabeam • Hyperthermia
Common Treatments Used For This Machine
Prostate Breast Lung Heterotopic Ossification Whole Brain Sarcoma Multiple Myeloma
Total Body Irradiation Bone Marrow Transplant
Total Skin Irradiation Mycosis Fungoides
Anal Rectal Lymphoma Head & Neck Cranial Spinal
Table and Field Limits
•Table Limit: •440 lbs
•Field Limit: •40cm x 40cm •120 MLC leafs
•80 leafs are 0.5 cm •40 leafs are 1 cm
Field Limits • Longitudinal:
– Controlled by Jaws
• 5cm, 2.5cm, and 1cm
– Maximum Longitudinal treatment field
• 145 cm
• Ant/Post and Left/Right
– Limited by the Field Of View
• FOV is 40 cm across
Common Treatments • H&N Cancers
• Pancreas
• Liver
• Esophagus
• Rectal
• CranioSpinal
H-N
Pancreas
Craniospinal Re-Irradiation
Case Description • 4 year old male
• PNET (Primitive Neuro Ectodermal Tumour)
• Underwent gross total resection
• Dose – 36 Gy to the craniospinal axis
• Posterior Fossa Boost – 55.8 Gy
Set Up Considerations Tomo: Patient Supine on
VacLoc. VacLoc pushed up to U-Frame with “A” headrest
Varian: Patient Supine on
VacLoc VacLoc pushed up to U-Frame with “A” headrest
• Tomo (MVCT) – Scan 4cm at L-Spine
• Make shifts to patient, not table
• Write down table corrections
– Scan 4cm at T-Spine
• Write down table corrections
– Scan 4cm at C-Spine
• Write down table corrections
– Scan from mid-skull to mid C-spine
• Compare table corrections
Comparing Tomo vs. Varian
IMAGING PROCEDURES Time: 15 to 25 min
Comparing Tomo vs. Varian
IMAGING PROCEDURES • Varian
– Day 1 • 9 to 12 images- one for each field
– 3 Right Lateral MV Portals – 3 Left Lateral MV Portals – 3 Posterior/Anterior MV Portals
» 3 more if the spine field is long
• Time – 25 to 35 min
– Once a week • Lat and AP MV Portal • Time
– 4 to 7 min
Treatment Considerations
• Tomo –After imaging
and shifts • Watch patient
for movement
• Varian –After imaging and
shifts • Watch patient for
movement
• Table kicks (Yaw)
• Field matching
• Feathering
• Energy
– 6MV
• Duration
– 9 min 1.3 sec
• Gantry Rotations
– 19
• Couch Travel (Y-axis)
– 61.5 cm
TomoTherapy Plan
Varian Trilogy Plan • Rt Lat Brain Field
– Gantry: 270
– Collimator: 10
– Couch Rotation: 8
– Y1: 12.6, 13.1, 13.6 cm
• Lt Lat Brain Field – Gantry: 90
– Collimator: 350
– Couch: 352
– Y1: 12.6,13.1, 13.6
• Energy – 6MV
• PA Spine Field – SSD: 100
– Y2: 18, 17.5, 17 cm
What Modality Was Selected And Why
• The homogeneity of the dose was improved with the TomoTherapy plan
• The Tomo plan was able to decrease – Dose to the
• Brain Stem • Spinal Cord • Heart • Right and Left Cochlea • Pituitary
– Exit doses of all other organs
• All vertebral bodies received a dose of 15 Gy – Will allow consistent growth across the volume of the
patient’s vertebral body
Dose Volume Histogram
• Tomo Mean Dose – 23.7 Gy
• Varian Mean Dose – 38.2 Gy
Rt Cochlea
Lt Cochlea • Tomo Mean Dose
– 24.6 Gy • Varian Mean Dose
– 38.3 Gy
Side Effects Acute
• Brain injury • Patient had learning
disabilities from birth and after resection surgery
• Hearing loss
• Possible radiation necrosis in cerebellar peduncle
Chronic • Fatigue
• Skin erythema
• Taste changes
• Hair loss
• Nausea
• Vomiting
• Loss of appetite
• Weight loss
• Low blood counts
• 6 months after Radiation treatment
– Increased Appetite
– Improved memory
– Improved muscle strength
– Truncal weakness
• Tumor enhancement found on MRI 7 months after treatment
Patient Outcome
Patient Satisfaction • Patient, though young, was not afraid of the
TomoTherapy Unit
• Patient’s parents were concerned and intimidated at first
– They felt comfortable after explanation of TomoTherapy
Case Description • 78 year old woman
• Unresectable adenocarcinoma of the pancreatic head – 2.3 x 2.2 cm
• with involvement of the hepatic arteries and SMA
– T4N1
• RT w/ concurrent Xeloda – Dose: 45Gy + 14.4 Gy Boost to 59.4 Gy (33 fractions)
– Fiducial marker placement to assist in imaging
• Followed up by Gemcitabine
Set Up Considerations • TomoTherapy
– Supine – VacLoc – Wing Board – Knee Sponge – Bilateral Levelers and SCI
• Varian Trilogy – Supine – VacLoc – Wing Board – Knee Sponge – Bilateral Levelers and SCI
• Tomo (MVCT)
– Scan 15 to 25 slices
• 6 mm each slice
– Time
• 2 to 3 minutes
Comparing Tomo vs. Varian
IMAGING PROCEDURES
Comparing Tomo vs. Varian
IMAGING PROCEDURES
• Varian
– Cone Beam
• Time – 2 ½ to 3 ½ min
– ExacTrac
• 1 min
TomoTherapy Plan • Energy
– 6MV
• Duration
– 2 min 40 sec
• Gantry Rotations
– 14
• Couch Travel (Y-axis)
– 8.19 cm
Varian Trilogy Plan • ARC Field 1
– Clockwise
– Gantry: 181 – 179 deg
– Collimator: 10 deg
– MU: 179
• ARC Field 2
– Counter Clockwise
– Gantry: 179 – 181 deg
– Collimator: 350 deg
– MU:224
• Energy
– 10 MV
What Modality Was Selected And Why
– Both plans were nearly the same • Tomo gave less dose to the spinal cord
– The implanted gold markers were not visualized well on the TomoTherapy unit
– Moved to the Varian Trilogy after 540 cGy
• Fatigue
• Abdominal pain
• Slight weight loss
• Slight Appetite loss
• Back Pain
• Nausea
– Was under control by end of treatment
• Dry mouth
Side effects
Patient Recovery • Fatigue began to decrease a week or two after
treatment finished
• Appetite increased
• Back pain did not subside
• Patient was found to have systemic disease 2 months after treatment
Patient Satisfaction
• Patient felt intimidated by the machine
– Overly complicated treatment
– Fear of the unknown was a factor at first
Case Description • 60 year old Male
• T3N2bM0 squamous cell carcinoma of the right tonsil
• P16 positive tumor treated with chemoradiotherapy
• Cisplatin (3 Cycles)
• Dose
– 70 Gy (35 fractions)
Set Up Considerations • Tomo
– Aquaplast mask with “B” headrest on Halycon board
• Varian
– Aquaplast mask with “B” headrest on Halycon board
• Tomo (MVCT)
– Scan 20 to 30 slices
• 4 mm each slice
– Time
• 3 to 4 minutes
Comparing Tomo vs. Varian
IMAGING PROCEDURES
• Tomo – After imaging and shifts
• Watch patient for movement
• Varian – After Imaging and shifts
• Watch patient for movement during Arcs
– Some treatments involve table kicks (Yaw adjustments)
Treatment Considerations
• Energy
– 6MV
• Duration
– 5 min 44 sec
• Gantry Rotations
– 28.6
• Couch Travel (Y-axis)
– 20.5 cm
TomoTherapy Plan
Varian Trilogy Plan • Energy
– 6MV
• ARC Field 2
– Clockwise
– Gantry: 179 – 181 deg
– Collimator: 350 deg
– MU: 252
• ARC Field 3
– Counter Clockwise
– Gantry: 260 – 100 deg
– Collimator: 5 deg
– MU:103
• ARC Field 1
– Counter Clockwise
– Gantry: 181 – 179 deg
– Collimator: 10 deg
– MU: 258
What Modality Was Selected And Why
• Varian decreased dose to:
– Spinal Cord
– Left Parotid
– Right & Left Cochlea
• Tomo decreased dose to:
– Mandible
– Hyoid
– Right Parotid
Dose Volume Histogram
• Tomo Mean Dose – 6.2 Gy
• Varian Mean Dose – 4.8 Gy
Rt Cochlea
Lt Cochlea • Tomo Mean Dose
– 6.6 Gy • Varian Mean Dose
– 3.9 Gy
Dose Volume Histogram
• Tomo Mean Dose – 30.3 Gy
• Varian Mean Dose – 31.7 Gy
Rt Parotid
Lt Parotid • Tomo Mean Dose
– 28.4 Gy • Varian Mean Dose
– 28.1 Gy
Side Effects • Last week of treatment:
– Mucositis
– Weight loss
– Brisk Erythema
– Extremely tired
– Sore throat
• Not eating much
• Drinking a bit
Side Effects/Recovery
• 3 months after treatment – Sore tongue
– Small amount of bone exposure on the left lingual surface of mandible
– No thrush, No mucositis
– Tonsils looked good
– Edema of the epiglottis and the arytenoids
– True cords looked good and moved freely
– Weight loss
Side Effects/Recovery
• One year out from treatment: – Eating well
– Swallowing fairly well
– Had dry mouth
– No sore throat
– No ear pain
– No cough
– He is very active in delivering phone books
Patient Satisfaction • Claustrophobic
– Had trouble with the mask and being in the bore the first 3 days
• Near the end of treatment patient felt treatment was almost not worth the effort
• 3 months/6 months/1 year later patient was very satisfied with the experience as a whole
TomoTherapy • Fear of losing patient set-up skills • MVCT for every patient can add up
– Time – Dose
• Boring – Nothing to do while patient is being
treated but watch the patient for movement
• Uncomfortable not being able to see the movement of the gantry and MLC’s
• If plan is changed tomo does not update the remaining fractions
• Takes time for patient to come out of bore in case of emergency
• The image quality could be better – It would be nice if kV imaging were
available
Varian Trilogy
• Needs a button that automatically takes the gantry and collimator to the zero position
• The image quality of the Port Films are not very good
• Clearance issues with the electron cone at 100 SSD
• Software crashes too often – Can take up to 10 minutes to correct
NEGATIVE
Opinions of Radiation Therapist (22)
Opinions of Radiation Therapist
Varian Trilogy • Can see patient with few
obstructions
• Can see movement of gantry, colli, and MLC’s during treatment
• Standard workhorse with solid imaging basics
TomoTherapy • Extremely easy to operate
compared to other machines
• Better treatment capabilities for pediatrics
• Dose is tracked by time and MUs – Same amount of time for every
fraction
• Can choose to avoid areas when doing a scan
POSITIVES
Opinions of Dosimetrists (5)
TomoTherapy • Can not do adaptive planning
as well as the Varian Trilogy
• Can not treat overly wide treatment fields
• When planning – Have to consider images quality
of MVCT
• Can not see TACE or gold seeds
Varian Trilogy • Patients can be accessed by
multiple users
– Plans can be altered by other user when saved without your knowledge
NEGATIVES
Opinions of Dosimetrists
TomoTherapy
• Excellent with long treatment fields
• Works well for midline structures – ie. Liver, Spine,…
Varian
• Can treat a wider scope of diseases
• Planning system is user friendly • i.e. Eclipse’s has a better resolution
when contouring
• Can create plans using automatic computer interpolation
POSITIVES
Opinions of Radiation Oncologists (5)
TomoTherapy • Seem to have side effects with
prone anal plans
• Length of the treatment times
• MVCTs are harder to read for image guidance
Varian Trilogy • Can not adjust for roll
• Does not treat long fields uniformly
NEGATIVES
Opinions of Radiation Oncologists
TomoTherapy • Varian can do almost any
treatment
• Can adjust for Yaw
• Easier for creating plans
Varian Trilogy • Better at concave structures
– Ie: head and neck
• Fewer setup variables on a day to day basis – Fewer opportunities for errors
– ie. Wedges, gantry angle, table angle
• Plans look better than Varian on large treatment volumes
• MVCTs are good for pts with hardware after surgery
• TOMO can adjust for roll
POSITIVES
Opinions of Physicists (6)
TomoTherapy • QA’s take longer
– Not able to use the same Isocenter for every patient’s QA
– Have to go back into the room and reset for each patient’s QA
• No clear separation for service mode • Needs dose technique options for MVCT
– Adjust for scanning different body thickness
• Drawing tools for structures are bad • Software support for film and water
scanner could be improved • Image quality could be better • Adaptive planning too complex
– Software tries to do too much
• Weekly chart checks have to be manually put into ARIA
– Corrected if have latest software version of Aria and Tomo
Varian Trilogy • CBCT’s algorithm can be 10% or
more off – Can not use image for planning
• Very difficult for commissioning – All the systems have to be
integrated
• IMRT (Rapid Arc) is not as good as TomoTherapy – Better if it could handle more data
• Then able to do more than 3 Arcs • There is more beam modulation
with its step and shoot than its Arcs – Limited to about 9 fields
» Leakage/Time
– Can’t handle the same amount of modulation
• Only good enough for prostate
NEGATIVES
Opinions of Physicists
TomoTherapy • Inverse planning easier than
other’s
• MVCT superior to CBCT – Can be used for planning
• High degree of beam modulation – Can manipulate beam more
Varian Trilogy • Easy well established QA system
• Planning tools are very user friendly
• Can treat nearly any type of cancer efficiently
POSITIVES
Opinions of Patients
TomoTherapy • Gantry head is intimidating
• Creaking noise of gantry – Worry it will fall
Varian Trilogy • Tomo bore can cause some
claustrophobia
• Tomo can be loud – Because of the cooling fans and leaf
movement
Conclusion • Both the TomoTherapy and Varian Trilogy machines have their positives
and negatives • The biggest complaints with the TomoTherapy:
– Poor imaging – Lack of flexibility with the software
• The biggest complaints with the Varian Trilogy: – Glitches in the software
• Causing down time
– Inability to treat long fields • Without feathering or matching
• The most mentioned positives about TomoTherapy: – Not having to worry about the gantry and table position during treatment – Ability to treat long fields
• The most mentioned positives about the Varian Trilogy: – It can handle almost any type of treatment – You can see the actual field on the patient
Bibliography
IMAGES 1. http://faculty.ksu.edu.sa/73860/Pictures%20Library/Forms/DispForm.aspx?ID=11 2. http://www.zimmerspine.eu/z/ctl/op/global/action/1/id/9027/template/PC/navid/9989 3. http://avandia-sideeffects.com/ 4. http://www.rsc.org/chemistryworld/Issues/2007/February/FirstDrugFatDogs.asp 5. http://jessicambabyblog.blogspot.com/2011/07/baby-genius.html 6. http://www.personal.psu.edu/afr3/blogs/SIOW/2011/10/the-elephants-trunk.html 7. http://www.greatlandings.com/2012/06/22/my-heart-will-go-on/ 8. http://www.marshfieldclinic.org/patients/?page=ent_ear_cochlea 9. http://www.nlm.nih.gov/medlineplus/pituitarydisorders.html 10. http://themusicgates.blogspot.com/2011/07/rolling-stones-i-cant-get-no.html 11. http://radiology.rsna.org/content/255/2/578.figures-only 12. Thank you to
1. Varian 2. Novalis 3. Accuray (Kelly McDonald) 4. Coworkers 5. Chief therapist 6. Onocologists 7. Physists 8. Dosimitrists