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Potential role of Image Guided Radiotherapy in locally advanced C ancer C ervix.

Potential role of Image Guided Radiotherapy in locally advanced C ancer C ervix.

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Potential role of Image Guided Radiotherapy in locally advanced C ancer C ervix.

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  1. Potential role of Image Guided Radiotherapy in locally advanced Cancer Cervix. Dr.Vikas Roshan MD, ECMO, CCEPS, PDCR. IGRT Fellow NUCI-NUS Singapore. Clinical Fellow NCCHE, Japan. Consultant Radiation Oncology, SMVDNSH.

  2. SMVDNSH 2016-2017 n=240 Cancer Types in SMVDNSH Department of Radiation Oncology,2017

  3. SMVDNSH DATA • Total no of patients 44 • Age range 32-84 years • Stage I-1(2%), STAGE II-3 (6%), STAGE 3- 36 (81%), Stage IVA-04 (9%) • Radiation dose 50.4 Gy/28# followed by ICRT X3# • VMAT 100 % • Radical CRT 39 (88%) patients • POCRT 3 (6%) • PALL RT 2 (5%)

  4. No grade II,III,IV GU toxicity • Two years follow up, 4 (9%) patients devloped distant recurence.Late toxicity rectal bleed grade 2, 2 patients.(4.5%) • DVT total 3 patients,one diagnosed during treatment. • RT Interruption nil and tolerated well • No Skin Toxicity • One patient died after disseminated disease. • 40 patients on follow up without clinically evident disease.

  5. 5 year survival from FIGO 2005

  6. IGRT Definition • Radiation therapy that employs imaging to maximize accuracy and precision throughout its entire process. ACR-ASTRO practice parameter 2014

  7. IGRT Concepts ICRU 50 ICRU 29 ICRU 62

  8. Key objectives Maximize dose to Tumour Avoid adjacent critical structures High quality efficient delivery

  9. WORKFLOW OF IMAGE GUIDED RT

  10. IGRT workflow X,Y,Z Table Correction Image display and registration on XVI WORKSTATION Comparison of target position with adaption of beam aperture MOSAIQ for on-line or off-line registration and stored in database XVI Image Acquisition And reconstruction Image export to TPS

  11. WHY IGRT

  12. Evolution of Radiation Oncology- Sharp Gun but a blurred target ?

  13. Sources of uncertainties • Inter-fraction (between fractions) • Setup: weight loss, rotation, etc. • Organ movement Physiological filling/emptying(bladder/rectum/emptying) • Intra-fraction (during treatment) • Set up Discomfort/tension, uncontrolled movement. • Organ movement Lung, bowel gas, peristalsis ,etc.

  14. IGRT picks up changes in oars

  15. When We Inspire Others Our people work at their best. They not only take on big challenges, they are committed to inspiring others. The resulting ripple effect continues to inspire individuals and companies around the world.

  16. 43 patients were evaluated Stage I-III • Pelvic arteries were contoured on non–contrast-enhanced CT simulation images of 43 • patients with cervix cancer, FIGO Stages I–III. Vessel contours were hidden, and conventional pelvic fields were • outlined: (1) anterior/posterior fields (AP): superior border, L5–S1 interspace; inferior border, obturator • foramina; lateral border, 2 centimeters lateral to pelvic brim. (2) Lateral fields (LAT): Anterior border, • symphysis pubis; posterior border, S2–S3 interspace. Distances were measured between the following: (1) • bifurcation of the common iliac artery and superior border, (2) external iliac artery and lateral border of the AP • field, and (3) external iliac artery and anterior border of the LAT field. The distances were considered as • “inadequate” if <15 mm, “adequate” if 15–20 mm, and “generous” if >20 mm.

  17. Imaging used in IGRT

  18. KV Imaging 2D/2.5D • 2 or more planar images are acquired at orthogonal angles. • It allows measurement in three directions anterior-posterior/lateral/superior-inferior • 2D/2.5D IGRT with Mosaiq setup intelligence(orthogonal pair of images)

  19. MVI EPI (I-ViewGT) • Standard feature in most Linear Accelerator • Contrast issue with bone , soft tissue and air can be poorly represented in MV-EPI.

  20. 3D Imaging • Volumetric imaging • Internal structures can be visualized • Cone beam CT/Megavoltage CT/CT on rails/Ultrasound • Cone Beam CT(CBCT) is a KV tube mounted at 90 degree to the linac head. • We can take both KV/MV imaging. • Precise registration of acquired CBCT/MVCT with reference CT • No need for surrogate markers • We can match the structures as defined in TPS • Large field of view.

  21. New Generation of IGRT • 4D Cone Beam CT • MR guidance MRguidedRT/MRIdian/VIEWRAY

  22. Correction • Real time tracking • Online (IGRT) Systematic and Random errors • Offline Systematic errors

  23. Benefits of IGRT • Conformal distribution to Tumour and OARS • Dose escalation • Verification of Applicator Position • Normal Tissue Dosimetry

  24. Plan of the day

  25. See better, plan better, deliver better • Opportunity to customize plan/treatment to patient anatomy(adaptive). • Tight conformance so confirm target first • High resolution images before treatment delivery • Unless you know the target position you can precisely miss it.