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Apinorasethkul
Apinorasethkul
Disclaimer
This presentation is not sponsored by any vendor nor is it
endorsing one VMAT system over other systems. The material
presented is based on our planning experience. The intention
of this talk is meant for educational purposes. Each technique
discussed should be evaluated on a case by case basis.
Outline
Why RapidArc?
What is RapidArc?
IMRT!!
IMRT
RA
Planning a RA plan
Contours
Targets
Organs at risk
Avoidance structures
Fields
Choose favorable arc
angles
Optimize
Planning objective
templates
(D) PTV_5400
Anterior Cooler
Posterior Cooler
Dose Spills
10
Dose Spills
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12
13
14
Dose Spills
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Fields
Maximum number of 10
arcs
Each arc needs at least 30
degrees
More arcs = more control
points = more potential for
dose modulation
Maximum dose rate
should be used for the
given energy mode
Increase the dynamic range
of modulation
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Fields
Center isocenter
Choose optimal arc angles
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Fields
Isocenter
Clearance issues
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Fields
Arc angle clearance
Clearance issues Arc1:136131 Arc2: 220225
Collides
Clears
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Multiple Arcs?
What is the optimal number of arcs?
More # of arcs, more modulation, expect to increase plan optimality
Example with unilateral H&N
1 partial arc vs 2 partial arcs (Total MUs: 392 vs 406)
Treatment volumes receive similar coverage. Normal tissue organs
are generally better with 2 arc plan. Lower global max with 2 arc plan.
Esophagus
Brachial
Plexus
Oral Cavity
Larynx_glottic
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Multiple Arcs?
What is the optimal number of arcs?
2 partial arcs vs 3 partial arcs (Total MUs: 406 vs 434)
Differences are not significant or not at all.
Need to balance among the time for patient on the table, more MUs,
and benefits of increasing the number of arcs.
Esophagus
Brachial
Plexus
Oral Cavity
Larynx_glottic
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Fields
Set up collimator angles
Tongue and groove effect
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Optimization
Optimization templates
Save time by inserting objectives
Upper
Lower
Mean dose
Set NTO objectives
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Optimization
Resolution Levels/Steps
Iterative optimization process multiple resolution levels
Hold allows user to make changes to objectives before next resolution
level
As resolution levels increase, the penalty function decreases
Beam parameters and beam segments change as penalty function
changes
Algorithm corrects for the change in parameters
Leaf motions are created during optimization (IMRT is after)
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Optimization
Resolution Levels/Steps
Levels 1-2: majority of optimization, most flexible to make changes in
optimization
Levels 3-4: focus on making the fluence treatable within the set arc(s)
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Optimization
Line chart
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Optimization
Bar chart
Shows which structures contribute most to the overall objective
function
Structures that are not doing well will be at or near top of chart
Length of bar indicates that structures contribution to overall objective
function relative to other structures.
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NTO
What is NTO?
Normal Tissue Objective
Prevents hotspots in normal tissue
Produces a sharp dose gradient around target volumes
to take into account the decrease in dose level as the distance
from targets is increased
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NTO
30
NTO
Without NTO
Higher global max dose
Hot spot on axial slice is outside PTV volume.
Use coolers
No significant save on OAR doses on one or the other.
NTO
No NTO
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Collimator Angles
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10 / 350
30 / 330
45 / 315
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10/350
Total MUs: 406
30/330
Total MUs: 418
45/315
Total MUs: 412
No significant difference
10 and 30 collimator angles are similar.
45 collimator angle gives higher normal structure doses.
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10 / 350
30 / 330
45 / 315
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37
38
39
40
41
42
43
44
45
10/350
Total MUs: 446
30/330
Total MUs: 563
45/315
Total MUs: 521
46
10 / 350
30 / 330
45 / 315
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48
49
50
51
52
53
54
55
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10/350
Total MUs: 416
30/330
Total MUs: 480
45/315
Total MUs: 516
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Limiting X-Jaws
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59
60
61
62
63
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10 / 350
30 / 330
45 / 315
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66
67
68
69
70
71
72
73
74
10/350 + 15 X-jaw
Total MUs: 886
30/330 + 15 X-jaw
Total MUs: 677
45/315 + 15 X-jaw
Total MUs: 647
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30/330
Total MUs: 563
45/315
Total MUs: 521
10/350 + 15 X-jaw
Total MUs: 886
30/330 + 15 X-jaw
Total MUs: 677
45/315 + 15 X-jaw
Total MUs: 647
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10 / 350
30 / 330
45 / 315
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78
79
80
81
82
83
84
85
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10/350 + 15 X-jaw
Total MUs: 499
30/330 + 15 X-jaw
Total MUs: 497
45/315 + 15 X-jaw
Total MUs: 527
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10/350 + 15 X-jaw
Total MUs: 499
30/330
Total MUs: 480
30/330 + 15 X-jaw
Total MUs: 497
45/315
Total MUs: 516
45/315 + 15 X-jaw
Total MUs: 527
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Intermediate Dose
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90
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PTV 5600
PTV 5950
PTV 7000
No intermediate dose
With intermediate dose
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No intermediate dose
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Brainstem
52Gy max intermediate dose
54Gy max no intermediate dose
Right Ear
Right parotid
Left Ear
No intermediate dose
With intermediate dose
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Jaw Tracking
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Jaw Tracking
Enable jaw tracking in Truebeam
Keeps the collimator jaws as close to the MLC aperture as
possible
Minimize leakage between MLC leaves
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Jaw Tracking
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Jaw Tracking
Jaw Tracking plan
at 17
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Jaw Tracking
Jaw Tracking
No Jaw Tracking
Jaw Tracking
SBRT
Small volumes
Measurements needed for small field size
May not be suitable for jaw tracking on very small volume.
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Avoidance Sector
101
102
103
104
105
Separate Arcs
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Avoidance Sector
107
Separate Arcs
108
Avoidance Sector
109
110
Right Cochlea
111
Summary
112
Questions
113
Acknowledgements
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