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Disclosure
Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths by Sex, 2010
Spectrum of NSCLC
RT+Chemo+/-S
Locally
advanced
Surgically
resectable
Metastatic
Surgery+/- Chemo
or SBRT
Chemo+ palliative RT
and palliative care
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Any T1a-T3 N2 M0
Stage 3A T3 N1 M0
T4 N0 or N1 M0
T4 N2 M0
Stage 3B
Any T1aT4 N3 M0
MLD
Seppenwolde et al IJROBP 55(3) 724-735
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IMRT/VMAT/ 4D Radiotherapy
dose painting
Dose escalation
Toxicity prediction
4D Radiotherapy
Encompass motion
Mean position
External surrogate
Gating
Internal surrogate
Breath Voluntary
hold Assisted
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Gating
Internal surrogate
Breath Voluntary
hold Assisted
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Gating
Internal surrogate
Breath Voluntary
hold Assisted
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Gating
Internal surrogate
Breath Voluntary
hold Assisted
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4D Radiotherapy
Encompass motion
Mean position
External surrogate
Gating
Internal surrogate
Breath Voluntary
hold Assisted
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4D radiotherapy
Technology Patient
simple
– Standard delivery – Free breathing
– ABC
– Breathold
complex
– Real time tracking – Anaesthesia
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Mirror
Abort button
Mouthpiece
Courtesy of Elekta
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Breath hold
volume
(Threshold Vol)
Tidal volume
Breath
hold time
Standby
Active
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Planning CT
– 83% (25 out of 30) tolerate ABC mean age ~70yrs old
– Mean breathold time 22 sec+/-6sec
Panakis, R&O, 2008
Patient Questionnaire
Very
much
Quite a
bit
A little
Not at all
ABC reproducibility
– 18 patients: induction chemo then radical RT 64Gy/30#,
– treat each # with ABC
– 3 consecutive ABC planning CTs
– and 1 ABC CT mid RT, and 1ABC CT end RT
Tumour reproducibility
Week 6
Week 3
Week 1
Brock, IJROBP, 2010
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Pt 1
Pt 2
50
Pt 3
45 Pt 4
40 Pt 5
35 Pt 6
Pt 7
30
Time
Pt 8
25 Pt 9
20 Pt 10
15 Pt 11
Pt 12
10
Pt 13
5 Pt 14
0 Pt 15
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Fraction
Overall Average 15.8 mins
max.
inhale
max.
exhale
IMRT/VMAT/ 4D Radiotherapy
dose painting
Dose escalation
Toxicity prediction
60 Gy in 8 fractions of 7.5 Gy
Alternate days over 3 weeks
Brock et al
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IMRT/VMAT/ 4D Radiotherapy
dose painting
Dose escalation
Toxicity prediction
2 strategies:
– ‘stop-go’ CBCT
– Half scan
– ~70sec with patient in both breathold and free breathing
– filterS10/20, gantry starts 340-ends 180
– Time spend in breathold during the scan 66%(52-81%)
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Pre match
Post match
Acknowledgements
William Beaumont Hospital
RMH Physics
RMH radiographers
RMH Imaging
The Royal Marsden
Thank you