Where you find the city of Ulm
Virtual Simulation and Verification in Total
Body Irradiation using ACQSIM and an
EPID with Extended Image Detection Unit
Ulm
J.E. Salk
San Antonio
University of Ulm
Department of Radiotherapy
University of Ulm
Objectives
Department of Radiotherapy
• 2 Varian Clinac 2300C/D + 1 Clinac 600C
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2 static + 1 dynamic MLC
Enhanced Dynamic Wedge
Varis R&V
Portal Vision (Mark 2)
• Picker CT PQ5000
– 2 VoxelQ & AcQSim
• 2 CadPlan TPS Servers
Objectives
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan
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TBI protocol at the University of Ulm
TBI treatment facility
EPID with extended Image Detection Unit for TBI
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan
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TBI protocol at the University of Ulm
TBI treatment facility
EPID with extended Image Detection Unit for TBI
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
3D Treatment Planning and Verification
with CadPlan and AcQSim (Step 1)
AcQSim
CT Images
Contours
Ref.-Point (=Marked IC)
Treatment Plan (optional)
CadPlan
CadPlan Dose Optimization
CadPlan Dose Calculation
BEV for adjustment of MLC
3D Treatment Planning and Verification
with CadPlan and AcQSim (Step 2)
axial
coronal
sagittal
3D
Digitally Reconstructed Radiographs (DRR)
CadPlan
Field Parameters
Monitor Units
Isocenter
Field Parameters
MLC, etc.
VARiS Server
AcQSim
Digitally Composited Radiographs (DCR)
pa Beam
Lateral Beam
3D Treatment Planning and Verification
with CadPlan and AcQSim (Step 3)
AcQSim
DRR/DCR
DRR
DCR
VARiS Vision Server
DRR/DCR
Film
Multimodality Image Fusion
Isocenter Verification with PortalVision
Electronic
Portal
Image
Digitally
Reconstructed
Radiograph
MRT Image
CT Image
Interim Summary
Total CNS Irradiation
• AcQSim is an essential tool for many clinical situations
• Virtual Simulation provides more information
• CadPlan can be used more efficiently
Verification
Virtual Simulation
(adjustment of beams)
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Sagittal Reconstruction
Provision of reference DRR
DRR
Total Body Irradiation
Objectives
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
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TBI protocol at the University of Ulm
TBI treatment facility
EPID with extended Image Detection Unit for TBI
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
(import beams from TPS)
University of Ulm
• Conditioning
• Total
patients with leukemia for BMT
Dose: 12 Gy
• 6 Sessions within 3 days
• Lung Dose: 10 Gy
AML and ALL: Radio-Immuno Therapy (Rh-188):
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Kidney Dose: 10 Gy (RIT) + 7 Gy (TBI)
TBI History and Progress
Objectives
University of Ulm
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
• 90 Patients (Oct 97 - Sep 99)
100
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Number of Patients (cumulative)
90
with RIT
80
without RIT
70
60
50
40
30
20
10
0
Oct 97
Dec 97
Mar 98
Jun 98
Sep 98
Dec 98
Mar 99
Jun 99
Sep 99
39 Patients with RIT + 51 Patients without RIT
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TBI protocol at the University of Ulm á
TBI treatment facility
EPID with extended Image Detection Unit for TBI
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
Total Body Irradiation
Objectives
Machine and Treatment Room Layout
ap beam: prone position
pa beam: supine position
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PV XL
SSD = 5.10 m
Treatment Room
Clinac 600C
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
Treatment Room TBI
Treatment Room
Clinac 2300 C/D
Portal Vision XL:
An EPID with Extended Image Detection Unit
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TBI protocol at the University of Ulm á
TBI treatment facility á
EPID with extended Image Detection Unit for TBI
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
Portal Vision XL:
An EPID with Extended Image Detection Unit
• 2 x 2 standard PortalVision IDUs
Sensitive Area:
65 x 65 cm2
512 x 512 Electrodes
= 262144 pixels
Spatial Resolution:
1.27 x 1.27 mm2
Build Up Plates
Optimized for 6 MV
• Lead shielding
for electronic
parts
Portal Vision XL:
An EPID with Extended Image Detection Unit
Portal Vision XL:
An EPID with Extended Image Detection Unit
• Fully closed
housing
• mounted on rails
• Fully closed
housing
• mounted on rails
Objectives
VARiS Vision Network Layout
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
Additional
VarisVision
Workstations
CadPlan
Workstations
Network
printers
VARiS Vision
Server
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TBI protocol at the University of Ulm á
TBI treatment facility á
EPID with extended Image Detection Unit á
Integration in VARiS Vision
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
VoxelQ &
AcQSim
Workstations
PVI Acquisition Stations
Ximavision
Workstation
IAS 2
IAS 2
DRS
PQ 5000
PortalVisionXL User Interface
Ximatron
Standard IDU
Clinac with
TBI option
IDU XL
Objectives
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
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TBI protocol at the University of Ulm á
TBI treatment facility á
EPID with extended Image Detection Unit á
Integration in VARiS Vision á
TBI Treatment Planning with AcQSim
TBI Delivery and Verification
TBI treatment planning:
TBI treatment planning:
Multiplanar Reconstruction
Lung tissue density
ρLung [g/cm3] = 1+HU/1000 (for HU < 0)
TBI treatment planning:
TBI treatment planning: Virtual Simulation
Dose Calculation
3D Reconstruction
Axial CT
Digitally
Reconstructed
Radiograph
Objectives
TBI treatment setup
• Overview: Treatment Planning and Verification
with AcQSim and CadPlan á
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TBI protocol at the University of Ulm á
TBI treatment facility á
EPID with extended Image Detection Unit á
Integration in VARiS Vision á
TBI Treatment Planning with AcQSim á
TBI Delivery and Verification
Patient prepared for treatment
in supine position,
radioopaque markers on
anterior skin
PortalVision XL in
operating position
Online Matching
Clinac ready for
Beam On
Digitally Reconstructed
Radiograph
Electronic Portal
Image
• Gantry rotated
• Couch retracted
• TBI Accessory
• TBI Flatness Filter
Online Matching (cont’d)
Digitally Reconstructed
Radiograph
Electronic Portal
Image
Final Summary and Conclusion
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Extended SSD beam setups and improved localization
AcQSim is smoothly integrated to VarisVision network
EPID image acquisition time of approximately 2 seconds
Image quality suitable for verification of shielding blocks
Monitoring of patient during the treatment
Combination of AcQSim and EPID is a
good investment for fast and precise TBI
The city of Ulm and the river Danube
The city of Ulm and the river Danube