Treatment Planning of
Complex Cases: Strategies
and Tradeoffs
Teamour (Tim) Nurushev, PhD
Director of Clinical Physics
Henry Ford Health System
Educational Session
Anaheim
AAPM 2009
What Makes a Case Complex?
Lack of communication in the team
Simulation and planning image quality
Volume delineation
Limitations on beam directions
Anatomical site
Critical organ dose limitations
Planning algorithms
Length of treatment
Setup reproducibility
Anatomy constancy
4D related issues
Educational Session
Anaheim
Outline
What makes a case complex?
How do we sort and approach complex
cases
Case 1. Anal Canal and Prostate Bed
Case 2. Bilateral Breast
Case 3. Maxillary Sinuses
Educational Session
Anaheim
AAPM 2009
Lack of Communication
Preparation instructions to patients for simulation
day
Simulation instructions to CT tech
Setup instructions to dosimetry and therapy
Physician treatment intent
Patient start time
Physics responsibilities
Ongoing care change orders
Communications to outside information sources
AAPM 2009
Educational Session
Anaheim
AAPM 2009
1
Simulation and Planning image quality.
Volume delineation
Issue
Tradeoff
Planning Limitations
Limitations on dose coverage due to
Missing information from
simulation-larger scan
length, larger bore
Higher dose to Pt and higher
cost of equipment
Target and critical organ
delineation –overlapping
volumes
Imaging artifacts, HU
calibration, conversion to
More complex planning,
multiple optimization
volumes and cost functions
More time on algorithm QA
and verification
Planning algorithms, how good is yours?
Will lead to non-reproducible
setup
Applicable to Brachytherapy
Patient preparation
Educational Session
e
Anaheim
AAPM 2009
Geometric Limitations
– Beam directions
– Anatomical site
– Critical organ dose limitations
– Hot spots, fake OARs, etc.
Presenting plan for review
– Better modeled, but “worse looking”
– Lung, new way to Rx?
Educational Session
Anaheim
AAPM 2009
Further Complications
Length of treatment
– Better targeting – more time, more dose
– Longer delivery – different RBE, patient motion, setup change
Setup method sensitivity and reproducibility
– Setup and imaging methods
Anatomy constancy due to:
– Tumor response to Tx
– Daily variations
4D related issues
– CBCT for lung – what to line up ITV to?
– Dose calculations on all phases?
Particle therapy
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
2
Sensitivity to roll
Approach
Identify where the complication is
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Mental: Fortunately can consider it outside of planning
Initial patient preparation
CT simulation
Multimodality imaging
Beam placement
Calculation algorithm reliability
Verification
Treatment setup
Once labeled the case moves into a category of
“interesting” rather than “complicated”
Educational Session
Anaheim
AAPM 2009
Educational Session
Case 1
Anaheim
AAPM 2009
Intent
ICD9 154.2 Squamous carcinoma. Anal
canal, post-prostatectomy. T1NXMX
Curative intent
Total of 5 physician intents with differential
dosing of the treatment sites
Communication was a key to success
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
3
Anal Canal, PTV
Educational Session
Anaheim
AAPM 2009
Anal Canal, PTV 5
Educational Session
Anaheim
AAPM 2009
Anal Canal, PTV4
Educational Session
Anaheim
AAPM 2009
Anal Canal, PTV 6
Educational Session
Anaheim
AAPM 2009
4
PTV 6, BEV
Educational Session
Anaheim
Optimization
AAPM 2009
Optimization
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
Composite Dose
Educational Session
Anaheim
AAPM 2009
5
How to address this?
Anatomy Constancy
Adaptive approaches?
Case 2
Bilateral Breast with Supraclavicular
involvement
Would be an average case
However…
Prostate deformation caused by rectal filling.
Educational Session
Anaheim
AAPM 2009
Image Quality
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
Problems with Calculations
Educational Session
Anaheim
AAPM 2009
6
Volumes and Values
Educational Session
Anaheim
AAPM 2009
Composite
Educational Session
Anaheim
Educational Session
Anaheim
AAPM 2009
Anatomy Constancy
AAPM 2009
Educational Session
Anaheim
AAPM 2009
7
Case 3
Beam Positioning
Maxillary Sinuses
Proximity of critical organs
Minimal margins
Daily setup
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
Resulting Coverage
Educational Session
Anaheim
AAPM 2009
Educational Session
Anaheim
AAPM 2009
8
CBCT Setup
Educational Session
Anaheim
AAPM 2009
Improved Technology
Educational Session
Anaheim
AAPM 2009
CBCT Application
Educational Session
Anaheim
AAPM 2009
Novalis Tx
Educational Session
Anaheim
AAPM 2009
9
Conclusion
Thank You
Any case can be as complicated as you
allow it to be
Proper tools are required to address issues
affecting all steps of planning process
Multidirectional communication channels
should be kept open between all teams
Educational Session
Anaheim
AAPM 2009
Rabih Hammoud
Nicole Walls
Misbah Gulam
And other Physicists
Anne Reding
Corey Fraser
Kim Garbarino
And other Dosimetrists
Dr. Munther Ajlouni, Dr. Eleanor Walker
And other Physicians
Therapists and Nurses
Educational Session
Anaheim
AAPM 2009
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