TOMOTHERAPY IN UKRAINE.

GENERAL
ANALYSIS OF FIRST TREATMENT RESULTS

Gumeniuk K., Odarchenko S., Gumeniuk M., Zinvaliuk O., Synchuk D.

 Ukrainian center of
Tomotherapy
Kropyvnytskyy, Ukraine
 What is Tomotherapy
Tomotherapy or Helical Tomotherapy (HT) is a type of
radiation therapy where the radiation is delivered slice-
by-slice (hence the use of the Greek prefix Tomo-,
which means "slice").
HT is a form of computed tomography guided intensity
modulated radiation therapy (IMRT).
The method was developed since the 70s of the XX
century in Japan and the USA.
However, the implementation of therapeutic devices
became technically possible only in the 21st century.
 TomoTherapy system
TomoHD
Nominal energy
6 MV for treatment
3.5 MV for MVCT
Treatment fan beam width 1, 2.5 і 5 cm
Helical/static mode
85 сm SAD
IMRT with IGRT (xenon ion chamber)
FFF
Dose rate 850 сGy/min at Dmax 1.5 cm
based on the maximum beam field size
50 mm (longitudinal) x 400 mm (transverse)
Gantry characteristics at SSD=85 cm.
Gantry bore size 850 mm Long therapeutic field
Rotation time 40 cm (transverse diameter) x 135 cm
1-6 rotations per minute (longitudinal) for typical patient.
 Rotation Therapy
Components of Helical Tomotherapy

Binary MLC

Helical scanning is
implemented with
couch movement and
continuous gantry rotation 5
 Multileaf collimator (MLC)

Binary MLC
Leaf
• opened or closed Conventional
• created for beam modulation (IMRT) MLC
Leaf open/close time ± 20 ms
64 binary, pneumatically driven tungsten Leaf
leaves (32 on each side). • moved to the planned position
Leaf dimensions: • operated with motors
– 10 cm thick • designed to form a beam
– 2 mm wide on LINAC side;
– 3 mm wide on patient side;
projects to 6.25 mm along the transverse
axis at isocenter
 TOMO HD
TomoHelical TomoDirect
gantry rotation

Binary MLC
+ or
static position + Couch motion

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 TomoHelical
The TomoHelical delivery mode provides IMRT and 3D CRT
treatment delivery in a continuous (360°) helical mode. The
TomoHelical mode maximizes conformality and uniformity of
tumor dose coverage while minimizing exposure of healthy tissue.
During treatment delivery, the linear accelerator makes multiple
360° rotations around the patient while the couch passes through
the bore of the gantry. Targets of up to 135 cm in length can be
treated, with no need of the patient reposition and with no field
overlapping.

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 TomoDirect
The TomoDirect delivery mode is non-rotational delivery
mode with a discrete angle static beams. TomoDirect allows to
create treatment plans that include between 2 and 12 target-specific
gantry angles. It also allows the user to define the level of
modulation for the plan, including a 3D delivery mode. During
treatment delivery, all beams for each target are delivered
sequentially with the couch passing through the bore of the gantry.
Targets of up to 135 cm in length can be treated, with no need of
patient reposition and with no field
overlapping.

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 Treatment process

TREATMENT
IGRT DELIVERY
DQA
TREATMENT PLANNING

CONTOURING
PATIENT
IMMOBILISATION
CT IMAGING
Patient immobilisation
CT imaging
Contouring
 Treatment planning
All structures are divided into
two groups: targets and OARs.
Each group has its own hierarchy.
All the targets and OARs are set
according to priority level.

Plan settings:
- Position red lasers;
- Delivery mode (Helical or
Direct);
- Plan mode (IMRT or 3D);
- Field width (1; 2,5 or 5 cm);
- Pitch;
- IVDT.
Treatment planning

Targets group:
prescribed doses
(Gy), importance and
penalties are set to
volume (%) of target.
OARs group:
maximum doses and
dose constraints are
filled.
Importance values are
set.
 DQA

Gamma 3D
parameters
2% (3%) - distance
2 mm (3mm) – dose
difference
Plan is acceptable -
95%-100%

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 Treatment Delivery

1 Positioning 2 Imaging 3 Registration 4 Applying Shifts

5 Re-positioning and delivery

 Positioning
The TomoHD System includes stationary
green lasers for virtual isocenter and
moveable red lasers for patient positioning
and registration. Green laser is typically
used by physicists for quality assurance and
research procedures.
The position of moveable red lasers is
determined by the physicist during planning
process. Red lasers can be programmed to
go to a patient-specific position
• Initial patient setup typically involves
aligning patient according to red lasers
• After scanning, registering, accepting
registration results, and applying
registration results, red lasers move to
account for the registration results

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 Positioning
with red lasers

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 Image registration
- Manual and automatic registration methods (CT and MVCT images)
- The possibility of couch re-position and gantry angle changing
- Dose coverage visual control

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 IGRT:3D MVCT Imaging
CTrue
Imaging is made before each procedure:
• Quality image (no artifacts)
• Low absorbed dose (1-3 cGy)
 Treatment
Applying Shifts Start irradiation

Visual control
 Features
of Tomotherapy
• Fan beam
• Helical dose delivery (51 modulated beam projections
throughout one 360 degree rotation)
• Beam separation into beamlets (64 beamlets per one
projection)
• FFF
• Binary MLC
• Designed for IMRT plans with IGRT (CTrue Imaging)
• A new method of delivering irradiation for SRS and
SBRT

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 Features
of Tomotherapy
• MVCT can be used for dose calculation with no artifacts
from metal parts
• Use of moveable lasers for positioning
• Possibility of replacing the CT couch to the Tomo couch
• Beam Stop. The beam stop provides shielding for the
primary beam. The beam stop is aligned directly across
the primary beam source.

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 Advantages
of Tomotherapy
• Helical TomoTherapy covers a large range of
treatments Complex targets, Long Volumes
(Treatment field length up to approximately 135
cm), Multiple Tumor Sites, Common Treatment
Sites, Small Tumors
• ALL TomoTherapy patients may be imaged to
ensure correct beam and patient positioning
• Low dose, high quality imaging enables imaging of
every patient prior to each treatment fraction
• Daily imaging assures set-up accuracy and provides
the confidence to reduce margins
 Advantages
of Tomotherapy
• Low toxicity
• Low reactions
• Frequency of radiotherapy interruptions is reduced
• Good cosmetic results of treatment
• One continuous delivery
• 1 isocenter with no shifts
• No field matching
• Re-irradiation
• No risk of couch collision with gantry
Treatment sites

197 patients were

treated with TomoHD
during 2015-2016
 Treatment planning
Case 1
Brain metastasis
Therapeutic strategy:
irradiation of the brain taking
into account escalation of the
dose over metastatic areas.
Fractionation scheme was
chosen: 30Gy dose to the
whole brain delivered in 10
fractions with simultaneous
escalation of the dose to the
metastatic lesion to 40 Gy.
Critical organs: lenses, eyes,
optic chiasm, optic nerves,
brain stem.
 DVH WBRT SIB

Plan parameters:
field width was
2.5 cm, the MF
was 2.1, and the
pitch was 0.287.
The beam-on
time was 378 sec.

Dmin / D99% Dmax / D1%

PTVbrain (-PTVmts) 27,1Gy / 29,1Gy 40,1Gy / 31,4Gy
PTVmts 38,5Gy / 38,8Gy 40,7Gy / 40,5Gy
Lens R Dmax=9Gy Optic Nerve L Dmax=29,9Gy
Lens L Dmax=8Gy Optic Nerve R Dmax=29,8Gy
Eye R Dmean=13,1Gy Chiasm Dmax=29,9Gy
Eye L Dmean=12,3Gy Brainstem Dmax=30Gy
 Treatment planning
Case 2
Prostate cancer

Therapeutic strategy: The irradiation of

the pelvic lymph nodes with the dose up
to 54 Gy and the lymph nodes Mts was 64
Gy and the prostate was 73.6 Gy per 32
fractions.
Critical organs: bladder, rectum,
intestines, head of left and right femur.
 DVH Prostate SIB

Dmax / D1%
PTVLN 73,9 Gy / 58,1 Gy
PTVmtsLN 65,1 Gy / 64,8 Gy
PTVPr 75,8 Gy / 75,0 Gy
Dmin / D99%
PTVLN 51,2 Gy / 53,3 Gy
PTVmtsLN 61,9 Gy / 62,0 Gy
PTVPr 68,4 Gy / 71,0 Gy

Plan parameters:
field width was
2.5 cm, the MF
OARs DV15% DV25% DV35% DV50% was 2.1, and the
Rectum 50 Gy 40 Gy 33 Gy 29 Gy pitch was 0.287.
Bladder 72 Gy 68 Gy 64Gy 56 Gy The beam-on
Femoral head L - 22,6 Gy - - time was 422 sec.
Femoral head R - 22,0 Gy - -
 Treatment planning
Case 3
Re-irradiation Medulloblastoma

Therapeutic strategy: The сranio-spinal

irradiation with the dose up to 36 Gy per 20
fractions (whole brain was irradiated with
30Gy in 10 fractions in 2015).
Critical organs: lenses, eyes, optic chiasm, optic
nerves, brain stem, lungs, heart, liver, kidneys.
 DVH CSI
Lens R Dmax=5,9Gy
Lens L Dmax=4,9Gy
Optic Nerve L Dmax=31,1Gy
Optic Nerve R Dmax=29,0Gy
Chiasm Dmax=36,4Gy
Brain stem Dmax=36,5Gy
Lung R DV20%=9,9 Gy
Lung L DV20%=10,5
Gy
Kidney R Dmean=9,0 Gy
Kidney L Dmean=9,0 Gy

Plan parameters:
field width was
PTV Dmin / DV99% PTV Dmax / DV1% 5cm, the MF was
20,9Gy / 33,5Gy 38,7Gy / 36,9Gy 2.3, and the pitch
was 0.303.
The beam-on
time was 728 sec.
 Early treatment and
There
radiation
were only few acute
reactions results Esophagitis Stomatitis
radiation reactions which did 5% 2%
Rectitis Dermatitis
not exceed G1, G2. The most 6% 34%
frequent reactions were Anemia
dermatitis – 32%, epithelitis - 8%

15%, leukopenia - 15%, cystitis

– 15%, anemia – 8%, rectitis – Cystitis
6%, esophagitis – 5%, 15%
Epithelitis
stomatitis – 2% 15%
Prolongation Leukopenia
Partial 15%
15%
regression
56%
The analysis of early treatment’s
Complete results showed that there were
resorption 15% patients with prolongation of
10%
the disease; the complete
resorption was observed in 10%;
stabilization in 19%; partial
Stabilization
regression in 56%
19%
 Quality assurance
The risk of inadequate radiation
treatment can be minimized through the
systematic performing of a comprehensive
Quality Assurance (QA) program, which
involves programs for quality management
and includes periodic quality control of
equipment.
The quality control of treatment units is
carried out by special dosimetric equipment.
 Quality assurance
equipment
“Cheese Phantom”
with density plugs Slit Beam Virtual Water

Aluminum step wedge

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 Quality assurance
equipment
Water Tank kit for obtaining and analyzing
Radiation beam data

TomoElektrometer

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 Quality assurance
program
Daily Weekly Monthly Annual

Red lasers TQA Step Wedge Phantom based test x - alignment of source
initialization Static (TomoPhant + MVCT doses) (Source to MLC alignment)

TQA Basic TQA Step Wedge y - alignment of source

Image quality
Dosimetry Helical (Source to y-jaw alignment)
Static output and TQA Field Width/ y - alignment of source
Static output
energy Longitudinal profiles (Source to y-jaw alignment) TQA
Radiation safety Rotational y-jaw divergence/beam
Couch movement
system output centering
y-jaw/gantry rotation plane
Interrupted procedure alignment (y - jaw alignment
with axis of rotation)

Treatment beam field centering

Axial green lasers position

(Nominal distance to isocenter)

Couch position
 TomoTherapy
Quality Assurance (TQA)
The TQA application is a calendar-based
productivity tool that simplifies the collection
and analysis of machine performance data for
the TomoHD Treatment System. The
application leverages internally-generated data
to provide results quickly and easily. The TQA
application offers trending and reporting of
many system and dosimetric parameters that
allow physicists to monitor the performance of
the TomoHD System.
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 Some issues
Long time beamlets calculating.
The time of calculating may be reduced with using the
VoLO system, which comprises a computer node with high-
performance Graphics Processing Units (GPUs), coupled with
Accuray’s Non-Voxel Broad Beam (NVBB) algorithm.
TomoTherapy Contouring system has poor
functionality and it is not adapted for automatic creation of
any additional logical structures. Contouring system of other
manufacturers is needed to create additional contours. At
UCT MIM Contouring system is used. It allows to create
outlines automatically, according to presets for different
locations under local protocols. Similarly, the creation of
presets for TPS accelerates the preparation before starting of
plan optimization.
 Conclusions
• Homogeneous dose coverage of target.
• High dose conformity.
• Good tissue sparing.
• Setup verification is based on CT image registration.
• No beam hardening artifacts with tomotherapy Ctrue
verification.
• No need for invasive immobilization or fiducial markers
for radiosurgery.
• Helical tomotherapy delivery is efficient.
• Low OARs dose.
• Helical tomotherapy increases the capability of IMRT.