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““Accurate boostAccurate boost”” or or Simply Simply
AccuboostAccuboostZoubirZoubir OuhibOuhib MS DABRMS DABRLynn Cancer Institute ofLynn Cancer Institute of
Boca Raton Community HospitalBoca Raton Community Hospital
Disclosure:Disclosure:Advisory boardAdvisory board
Items to be discussedItems to be discussed
�� TechnologyTechnology�� Clinical reasons for such technologyClinical reasons for such technology�� DosimetryDosimetry�� Comparison with Electrons and 3DComparison with Electrons and 3D--CRTCRT�� Acceptance testingAcceptance testing�� Clinical casesClinical cases�� QuestionsQuestions
Big picture on management of Breast CancerBig picture on management of Breast Cancer
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AccuboostAccuboost System componentsSystem components
�� Mammography unitMammography unit�� CR for filmsCR for films�� Overlays for Overlays for TxTx fieldfield�� ApplicatorsApplicators�� HDR unit.HDR unit.�� NomogramNomogram for for TxTx timetime
Treatment system setupTreatment system setup
Why Mammography? undeniably, the best Why Mammography? undeniably, the best method to image/localize the method to image/localize the
lumpectomy site. lumpectomy site. ““Gold StandardGold Standard””
An alphanumeric An alphanumeric radiopaqueradiopaque grid built grid built into the paddle for applicator location.into the paddle for applicator location.
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Applicators (Tungsten)Applicators (Tungsten)
D-applicators: 45x66; 53x78 and 60x88 mm
Round Applicator:4,5,6,7,8
Advantage of DAdvantage of D--applicatorapplicator
Applicator and source pathApplicator and source path
Connector to transfer tube
Patient in treatment setupPatient in treatment setupM-L
direction CC direction
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DosimetryDosimetry of of AccuboostAccuboost
DosimetryDosimetry
�� MCNP5 basedMCNP5 based�� Work of Mark Rivard Ph.D.Work of Mark Rivard Ph.D.�� Breast Thicknesses from 30 to 80 mmBreast Thicknesses from 30 to 80 mm�� Applicators Ranging from 40 to 80 mmApplicators Ranging from 40 to 80 mm�� All materials accurately modeled, including All materials accurately modeled, including
ICRU 44 Breast Tissue definitionICRU 44 Breast Tissue definition……. Not . Not solid water analogsolid water analog
•(Med Phys 36(11) 5027—5032)
Monte Carlo Monte Carlo Data Data –– Transverse DoseTransverse Dose--Depth DistributionDepth Distribution-- Single SideSingle Side
Monte CarloMonte CarloData Data –– Single Axis Radial Dose DistributionSingle Axis Radial Dose Distribution
Single axis dose distribution - 5 cm breast, 6 cm applicator
0%
20%
40%
60%
80%
100%
120%
140%
160%
-8 -6 -4 -2 0 2 4 6 8
Distance from central axis ( cm )
Per
cen
to
fce
ntr
ald
ose 2.5 cm
2.0 cm
1.5 cm
1.0 cm
0.5 cm
Center
D istanceabove Breastcenter plane
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Dose distribution: opposed fieldsDose distribution: opposed fields Daily dose: 4 fieldsDaily dose: 4 fields
Resulting doseResulting dose When treating an APBI patient with 4 opposed fields When treating an APBI patient with 4 opposed fields (perpendicular), the skin dose In relation to the (perpendicular), the skin dose In relation to the
prescribed dose) is expected to be:prescribed dose) is expected to be:
25%25%25%25%
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1.1. 120%120%2.2. 50%50%3.3. 100%100%4.4. 70%70%
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D applicator: dose distributionD applicator: dose distribution
T.L.AD.D.
T.S.AD.D..
P.D.D..
The DThe D--Applicator is used for the following Applicator is used for the following reasonreason
25%25%25%25% 1.1. Appropriate geometrical dose coverage Appropriate geometrical dose coverage
2.2. The advantage of the dose distributionThe advantage of the dose distribution3.3. The better access to lumpectomy cavity close to the chest wallThe better access to lumpectomy cavity close to the chest wall
4.4. Shorter treatment timeShorter treatment time
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Resulting dose distribution Resulting dose distribution from four fieldsfrom four fields
Resulting Dose distribution for an Resulting Dose distribution for an Offset lesion Offset lesion
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Reasons for the technologyReasons for the technology�� Reduce Dose to the heart and lungReduce Dose to the heart and lung�� Less dose to surrounding normal tissueLess dose to surrounding normal tissue�� Conformal and Uniform Dose to targetConformal and Uniform Dose to target�� No geometric miss, excellent localizationNo geometric miss, excellent localization�� Ability to incorporate surgical and pathological Ability to incorporate surgical and pathological
information with respect to information with respect to ““margin at riskmargin at risk””. This leads . This leads to great flexibility in target design such that the boost to great flexibility in target design such that the boost can be as precise as a can be as precise as a ““targeted retargeted re--excisionexcision””
�� Lower skin, rib and Lower skin, rib and pectoralispectoralis muscle dosemuscle dose�� NonNon--Invasive technologyInvasive technology�� Easy to implement and useEasy to implement and use
Reduction of dose to heart and lungReduction of dose to heart and lung
Conventional Electron Boost – 90% isodose line grazes the lung & 50% isodose line penetrates deeply into the chest cavity
AccuBoost – The 10% isodose line barely penetrates the chest cavity
Full dose to the rib Less than 20%to the rib
Electrons vs. Electrons vs. AccuboostAccuboost
AccuBoost
<= APBI =>
Electrons– APBI =>
Three-Dimensional Dose Modeling of the AccuBoost Mammography-Based Image-Guided Non-Invasive Breast
Brachytherapy System for Partial Breast Irradiation
S.Sioshansi,1,2 J. R. Hiatt,2 M. J. Rivard,1 J. T. Hepel,1,2 G. A. Cardarelli,2 S. O'Leary,1 D. E. Wazer1,2
1Department of Radiation Oncology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
2Department of Radiation Oncology, Rhode Island Hospital, Brown University School of Medicine, Providence, RI
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Electrons vs. Electrons vs. AccuboostAccuboost
0.02N/SN/S0.04N/S0.01N/S0.02p-value
107.3(104.4-108.6)
102.3(94.7-104.3
2.1(2.1-2.2)
1(0.9-1.5)
2.2(2.3-2.4)
88.4(75.0-95.7)
13.1(8.3-27.3)
118(70-202)
Electrons
100.8(100.2-
103)
93.8(93.0-94.4)
2.1(2—2.1)
1.8(1.7-1.9)
2.3(2.2-2.6)
54.6(30.8-37.9)
21.1(19.2-26.7)
44(31—74)
Accuboostmedian
PTVD50(%)
PTVD90(%)
PTVDmean
(Gy)
PTVDmin(Gy)
PTVDmax(Gy)
PTVV100(cc)
PTVV110(cc)
PTVvol(cc)
0.010.020.01p-value
115.2 (113.2-121.4)99.9 (73.2-105.2)106.1 (104.4-108.6)Electrons
91.2 (81.5-100)18 (13.1-20.2)30.8 (24.0-53.6)Accuboost Median
Max. Skin Dose (%)Max. Lung Dose (%)Chest Wall Dose (%)
3D3D--CRT vs. CRT vs. AccuboostAccuboostFrom S. From S. SioshansiSioshansi PosterPoster
AccuBoost
<= APBI =>
3D-CRT– APBI =>
3D3D--CRT vs. CRT vs. AccuboostAccuboost
NS0.02NSNS0.05NSN/A0.01p-value
100.5(95.1-100.5)
97.6(97.1—
98.1)
38.6(38.2—
38.6)
32.0(30.0—
33.3)
40.0(39.7—
40.6)
51.8(34.8—
62.1)
0(0—0)
222(201-360)
3D-CRTMedian
100.8(99.9-102.2)
93.1(91.3--93.7)
39.5(37.1—
40.0)
33.9(29.3—
33.5)
45.4(42.7—
48.6)
54.4(47.7—
56.4)
22.2(18.9—25.6)
78(58—119)
Accuboostmedian
PTVD50(%)
PTVD90(%)
PTVDmean
(Gy)
PTVDmin(Gy)
PTVDmax(Gy)
PTVV100(cc)
PTVV110(cc)
PTVvol(cc)
0.040.020.01p-value
104 (103.5—106)91.9 (88.4—98)99.9 (95.1—100.5)3D-CRT Median
94.8 (76.5—101.1)18.7 (17.5—25.4)32.4 (27.4—88.4)Accuboost Median
Max. Skin Dose (%)Max. Lung Dose (%)Chest Wall Dose (%)
Summary of comparisonSummary of comparison
�� AccuBoostAccuBoost median max skin dose is 25% lower than electron median max skin dose is 25% lower than electron boost and 10% less than 3Dboost and 10% less than 3D--CRT.CRT.
�� AccuBoostAccuBoost delivers 70delivers 70--80% less dose to the chest wall and lungs. 80% less dose to the chest wall and lungs. PTV coverage is comparable between the techniques.PTV coverage is comparable between the techniques.
�� There is NSS difference between electron boost and There is NSS difference between electron boost and AccuBoostAccuBoostboost for the V110, boost for the V110, DmaxDmax,, DmeanDmean, or D90., or D90.
�� Electron boost plans have a lower median Electron boost plans have a lower median DminDmin than than AccuBoostAccuBoost boost (1.0 boost (1.0 GyGy vsvs 1.8 1.8 GyGy, p=0.039), but higher V100 , p=0.039), but higher V100 and D50. and D50.
�� The only significant difference between the APBI techniques is The only significant difference between the APBI techniques is slightly higher median D90 with 3DCRT (97.6% slightly higher median D90 with 3DCRT (97.6% vsvs 93.1% 93.1% p=0.016) and higher p=0.016) and higher DmaxDmax with with AccuBoostAccuBoost (45.4 (45.4 GyGy vs. 40 vs. 40 GyGyp=0.055).p=0.055).
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One of the major advantages of One of the major advantages of AccuboostAccuboost over 3D over 3D external beam isexternal beam is
25%25%25%25% 1.1. The dose reduction to the chest wallThe dose reduction to the chest wall
2.2. The dose reduction to the lungThe dose reduction to the lung3.3. The dose reduction (maximum dose) to the skinThe dose reduction (maximum dose) to the skin
4.4. All the aboveAll the above
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Geometric miss? Boost setupGeometric miss? Boost setup
�� CT imagingCT imaging�� U/S imagingU/S imaging�� ClipsClips�� ScarsScars�� OthersOthers
CT OPTIONCT OPTION(Electron and 3 D CRT)(Electron and 3 D CRT)
�� Clinical setup with CT Clinical setup with CT not accuratenot accurate
�� Geometric missGeometric miss
CT Original image on leftCT Original image on leftDelineation by 4 Delineation by 4 ““breast expertbreast expert”” MDMD’’s on rights on right
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U/S Option (External beam)U/S Option (External beam)
Princess Margaret study:Princess Margaret study:54 pts had U/S boost loc54 pts had U/S boost loc1) 65% had the clips inside 1) 65% had the clips inside
the boost fieldthe boost field2) 28% marginal2) 28% marginal3) 7% inadequate (clips 3) 7% inadequate (clips
outside U/S field)outside U/S field)
RingashRingash J, Whelan T, et alJ, Whelan T, et al RadiotherRadiother OncolOncol 20042004
Clips optionClips option
�� Not easily visible in U/SNot easily visible in U/S�� Obvious with MammographyObvious with Mammography�� Good reference for cavity identification and Good reference for cavity identification and
delineation: very helpfuldelineation: very helpful
Scar optionScar option�� Alone not reliable for Alone not reliable for
cavity identificationcavity identification�� Red: scarRed: scar�� Light bleu: CavityLight bleu: Cavity�� Green: electron fieldGreen: electron field
KEVIN S. OH, M.D. et alInt. J. Radiation Oncology Biol. Phys., Vol. 66, No. 3, pp. 680–686, 2006
AccuboostAccuboost optionoption
�� Mammography used to localize targetMammography used to localize target�� Breast is immobilized with compressionBreast is immobilized with compression�� No margin of errorNo margin of error�� Breathing motion eliminatedBreathing motion eliminated�� No target movement during treatmentNo target movement during treatment
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Acceptance testing for Acceptance testing for AccuboostAccuboost�� Dose profiles and distributions with films (Dose profiles and distributions with films (GafchromicGafchromic Film )Film )�� Verification of Applicators sizes, connections, dwell pointsVerification of Applicators sizes, connections, dwell points�� Output factor (Output factor (GyGy/min)/min)�� Verification of Treatment timeVerification of Treatment time�� Plate Separation (compression thickness)Plate Separation (compression thickness)�� Applicator Catheters (inspection and replacement)Applicator Catheters (inspection and replacement)�� Training for staff (therapists, Training for staff (therapists, dosimetristsdosimetrists) for the use and ) for the use and
interpretation of the interpretation of the MammoMammo. unit. unit�� Mammography & CR SystemsMammography & CR Systems
�� Calibrated on Site by Mammography system installerCalibrated on Site by Mammography system installer�� Form DD2579 filed with the state by ART, not for mammography butForm DD2579 filed with the state by ART, not for mammography but
for localization onlyfor localization only�� Typically Typically -- Facility adds one radiation emitting device to its license and Facility adds one radiation emitting device to its license and
monitoring protocolsmonitoring protocols
DosimetryDosimetry: single field: single field
Opposed fieldOpposed field DD--Applicator Applicator Dose Distribution Dose Distribution –– GafchromicGafchromic Film D60Film D60
Transverse Dose DistributionShort Axis
Planar Dose Distribution3 cm depth
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Output verificationOutput verification
1.69.689.530.9539.897371.822D 5.3-2
1.69.689.530.9539.897371.822D 5.3-1
2.110.4610.240.9479.904343.919D 4.5-2
1.910.4610.270.9509.904343.919D 4.5-1
1.74.154.080.4754.138434.721Round 7-2
2.04.154.070.4744.138434.721Round 7-1
2.54.454.340.4714.13940518Round 6-2
3.04.454.320.4694.13940518Round 6-1
3.54.734.570.4664.13938115Round 5-2
2.84.734.600.4694.13938115Round 5-1
% differenceManufacturerO.F.
Output factorReading(C)
Activity (Ci)Total Dwelltime(sec)
# dwellpoints
Applicator(cm)
Setup for clinical casesSetup for clinical cases
Typical setup Cranio-caudal Same patient Medio-lateral
Selection of applicatorsSelection of applicators
Cranio-caudal 6 cm applicator Medio-lateral 5 cm applicator
clipsApplicator
Exclusion for Exclusion for AccuboostAccuboost
�� Cavity too largeCavity too large�� Patients cannot tolerate compressionPatients cannot tolerate compression�� Cavity not easily identifiedCavity not easily identified�� Cavity too close to chest wall (even with D Cavity too close to chest wall (even with D
applicators)applicators)
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AccuboostAccuboost treatmenttreatment
�� Prior to external beam: easier on patients Prior to external beam: easier on patients �� Possibility of discomfort if to close to postPossibility of discomfort if to close to post--op. op. �� Half way trough the external beam: possibility of Half way trough the external beam: possibility of
discomfort (?)discomfort (?)�� Boost one or two days per week within the Boost one or two days per week within the
course of WBI? course of WBI?
Treatment time calculationTreatment time calculation
�� Based on Monte Carlo (MCNP version 5) Based on Monte Carlo (MCNP version 5) simulationsimulation
�� Backed by calibrated NIST traceable Backed by calibrated NIST traceable ionization chamber measurementsionization chamber measurements
�� For 4For 4--8 cm diameter applicators8 cm diameter applicators�� For 3For 3--8 cm thick breast8 cm thick breast�� Options for breast tissue or polystyreneOptions for breast tissue or polystyrene
Treatment time calculation: use of Treatment time calculation: use of nomogramnomogram
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RadOnc #
02/11/2010HDR Tx Date & Time 02/11/10 13:45 14:10Number of Treatment Fraction 3 3
Mammography gantry angle [degrees] 0.0 90.0Prescription dose [Gy] per Angle/fraction 1.00 1.00
6 I.5 5.5 I.5Round Round Click Drop-Down List
CONE applicator size [mm] 50 60 Click Drop-Down List
SEPARATION of plates [30-80 mm] 55 59 Click Drop-Down List
Prescribed % line [70-100%] 100% 100% Click Drop-Down List
Center dose rate [Gy/h] at each cone 8.36 7.33
Tx time [seconds] for each angle 432.0 489.6
Current Source strength [Ci] 6.705 6.703Catheter # 1111 2222 3333 4444
Dose Gy /cath 0.50 0.50 0.50 0.50Total Dwells /cath 15 15 18 18Total seconds /cath 216.0 216.0 244.8 244.8Dwell Positions Dwell time (sec) Dwell time (sec) Dwell time (sec) Dwell time (sec)
1 14.4 14.4 13.6 13.62 14.4 14.4 13.6 13.63 14.4 14.4 13.6 13.64 14.4 14.4 13.6 13.65 14.4 14.4 13.6 13.66 14.4 14.4 13.6 13.67 14.4 14.4 13.6 13.68 14.4 14.4 13.6 13.69 14.4 14.4 13.6 13.610 14.4 14.4 13.6 13.611 14.4 14.4 13.6 13.612 14.4 14.4 13.6 13.613 14.4 14.4 13.6 13.614 14.4 14.4 13.6 13.615 14.4 14.4 13.6 13.616 0.0 0.0 13.6 13.617 0.0 0.0 13.6 13.618 0.0 0.0 13.6 13.619 0.0 0.0 0.0 0.020 0.0 0.0 0.0 0.021 0.0 0.0 0.0 0.022 0.0 0.0 0.0 0.023 0.0 0.0 0.0 0.024 0.0 0.0 0.0 0.025 0.0 0.0 0.0 0.0
*Yang Y: Med Phy 36:809-815, 2009. Rivard M: Med Phy 36:1968-1975, 2009. **Calculation medium is breast equivalent.
Calculated by : Checked by: Z. Ouhib MS
nd & D Applicator Calculation, v6.0, Lynn Cancer Institute, BRCH
Accuboost Applicator Treatment CalculationPatient name:
ABS, MEETING
A. Schramm
Isocenter location = X, Y
Applicator Type
PrintPrintPrint
Treatment time calculationTreatment time calculation
�� Number of dwell points: 3 x applicator size for Number of dwell points: 3 x applicator size for round oneround one
�� Different for DDifferent for D-- applicatorsapplicators�� All dwell points should be usedAll dwell points should be used�� Step size equal 1 cmStep size equal 1 cm�� Source indexer 1500 mm for Source indexer 1500 mm for NucletronNucletron systemsystem
AcknowledgementsAcknowledgements
�� Ray Ray BricaultBricault, ART, ART�� Mark Mark RivardRivard, Ph.D., Tufts, Ph.D., Tufts�� ShirinShirin SioshansiSioshansi, M.D., Tufts, M.D., Tufts�� David David WazerWazer, M.D., Tufts, M.D., Tufts�� Greg Greg EdmundsonEdmundson M.S.M.S.�� Coral Quiet M.D.Coral Quiet M.D.
Questions??Questions??
