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Radiation dose painting in Head and Neck treatment: how far are we ?

Radiation dose painting in Head and Neck treatment: how far are we ?. Vincent GREGOIRE, MD, PhD, Hon. FRCR

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Radiation dose painting in Head and Neck treatment: how far are we ?

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  1. Radiation dose painting in Head and Neck treatment: how far are we ? Vincent GREGOIRE, MD, PhD, Hon. FRCR Radiation Oncology Dept., Head and Neck Oncology Program & Center for Molecular Imaging and Experimental Radiotherapy, Université Catholique de Louvain, St-Luc University Hospital, Brussels, Belgium

  2. This house believes that … • RO will be (even more) multidisciplinary… • RO will be conformal (e.g. IMRT, proton, hadrons)… • RO will be tailored (based on imaging and molecular profiling) and adaptive … • RO will be associated with targeted agents …

  3. The current practice:Conformality…?

  4. Intensity Modulated Radiation Therapy (IMRT) Radiotherapy in HNSCC Adaptive IMRT 2000

  5. Conformal radiotherapy and IMRT in Head and Neck Tumors DAHANCA: http://www.dshho.suite.dk/dahanca/guidelines.html EORTC: http://www.eortc.be/home/ Radio/EDUCATION.htm RTOG: http://www.rtog.org/hnatlas/main.htm

  6. Which CTV for the neck? Oropharyngeal Carcinoma Grégoire et al., 2000

  7. LIa LIb RP LII CT-based delineation of lymph node levels in the neck: Brussels- Rotterdam consensus guidelines Level Ia and Ib Ant. symphysis menti / platysma Post. hyoid bone / submandibular gland Lat. ant. belly of digastric m. (Ia) mandible / platysma (Ib) Med. ant. belly of digastric m. (Ib) Cra. geniohyoid m./mandible (Ia) mylohyoid m, submandibular gland (Ib) Cau. hyoid bone

  8. H&N IMRT practice heterogeneity among Dutch Radiation Oncologists Rasch et al., 2007

  9. IMRT for Head and Neck Tumors Oropharyngeal SCC T2-N0-M0 SIB-IMRT: 30x2.3 Gy 30x1.85 Gy PTV 69 Gy Larynx PTV 55.5 Gy PRV Spinal cord Left parotid Right parotid

  10. Acute toxicity with IMRT ≥ grade 3 mucositis: IMRT vs 3D-CRT Vergeer, 2009

  11. Parotid gland sparing in IMRT for HNSCC Nutting, 2009

  12. The current practice:Conformality…? Yes !

  13. The current practice:Tailoring…?

  14. The Gross Tumor volume (GTV) Daisne et al., Radiology, 233: 93-100, 2004

  15. 5 cm 5 cm 5 cm Macroscopy CAT Scan 18F-FDG PET Daisne et al, 2004

  16. CT-based target volume FDG PET-based target volume Impact of imaging modality on dose distribution Image-Guided Radiation Therapy in HNSCC

  17. Apport de l'imagerie fonctionnelle par Tomographie par Emission de Positrons (TEP) dans le ciblage biologique par radiothérapie de conformation (3D-CRT) et par modulation d'intensité (IMRT) de tumeurs ORL Validation protocol in locally advanced HNSCC Use of functional imaging with PET for target volume delineation in 3D-CRT/IMRT for head and neck tumors Prof. V. Grégoire, UCL St-Luc, Brussels, Belgium Prof. E. Lartigau, COL, Lille, France Dr. JF Daisnes, Cliniques St-Elisabeth, Namur, Belgium

  18. “Dose painting” by number… Flat dose Non-flat dose Far more efficient use of dose Mean Tumor Dose = 2 Gy Survival is non-flat (higher in resistant areas) More similar survival across entire tumor Courtesy of D. De Ruysscher

  19. “Dose painting” : the physics issue

  20. Biological heterogeneity [18F]-FDG TEP Registered autoradiography Résolution 2.3 mm Résolution 0.1 mm N. Christian, 2010

  21. Proliferation: 76Br-BFU Which biological pathways? … Hypoxia: 18F-EF3 Metabolism: 18F-FDG 11C-Met

  22. Spatially “complex” target FDG FLT CuATSM Jeraj et al, 2010

  23. The current practice:Tailoring…? Great hope but still in the research arena!

  24. The current practice:Adaptation…?

  25. 4D-IMRT The Cathedral of Rouen C. Monet, 1894

  26. CT MRI (T2) FDG-PET PRE-R/ (Week 2) WEEK 3 (Week 4) WEEK 5

  27. Variation in parotid volumes during RT-CH… (70 Gy – 3 courses on w1, w4, w7) Heterolateral parotid Homolateral parotid Mean slope: -1.03% / treat day (p<0.05) No shift Mean slope: -0.93% / treat day (p<0.05) Medial shift: 3.21mm after 25# (p<0.05) Castadot & Lee, 2010

  28. Variation in CT Target volumes during RT-CH (70 Gy – 3 courses on w1, w4, w7) CTVT 70 Gy, CT GTVT, CT Mean slope: -2.55% / treat day (p<0.05) Lateral shift: 1.52mm after 25# (p<0.05) Mean slope: -3.18% / treat day (p<0.05) Lateral shift: 1.26mm after 25# (p<0.05) Castadot & Lee, 2010

  29. Variation in prophylactic CTVs during RT-CH… (70 Gy – 3 courses on w1, w4, w7) Heterolateral CTVN 50 Gy, CT Homolateral CTVN 50 Gy, CT Mean slope: -0.47% / treat day (p<0.05) No shift Mean slope: -0.41% / treat day (p<0.05) Medial shift: 1.76mm after 25# (p<0.05) Castadot & Lee, 2010

  30. 0 → 14Gy 14 → 25Gy 25 → 35Gy 35 → 45Gy 45 → 69Gy + w2→w0 + w3→w0 + w4→w0 + w5→w0 Total Dose really received by each volume element of the patient Castadot & Lee, 2008

  31. P<0.001 Impact on dose distribution Classic CT-based planning Adaptive PET-based planning SIB-IMRT 30x2.3 Gy 30x1.85 Gy Planning V10 V50 V80 V90 V95 V100 Classic CT-based 100% 100% 100% 100% 100% 100% Adaptive CT-based 99% 100% 100% 85% 80% 66% Classic PET-based 99% 99% 98% 83% 82% 81% Adaptive PET-based 99% 100% 98% 73% 67% 58% Geets, 2007

  32. Dose distribution after biological adaptive IMRT Castadot & Lee, 2010

  33. The current practice:Adaptation…? Geometric adaptation, yes! Biologic & dosimetric adaptation, under validation!

  34. This house believes that … … conformal …, tailored …, and adaptive … Probably not too far … But don’t jump to quickly into routine practice… Wait for validation! How far are we?

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