Recent Advances In Brachytherapy: Unconventional ...amos3.aapm.org/abstracts/pdf/127-35266-418554...Recent Advances In Brachytherapy: Unconventional Applications of Brachytherapy

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  • RecentAdvancesInBrachytherapy:UnconventionalApplicationsofBrachytherapy

    59th AnnualNationalConferenceoftheAAPMAugust2,2017

    BenjaminP.Fahimian,PhD,DABR*ClinicalAssistantProfessor,AssociateDirector,TherapeuticMedicalPhysicsResidency,BrachytherapyPhysicsLead,StanfordUniversityfahimian@stanford.edu*FinancialDisclosures:None

  • Fahimian,AAPM2017,Slide:3

    Outline

    Wherearewe,andwherearewegoingwithclinicalapplicationsofbrachytherapy? Roleofbrachytherapyasafocaltechniqueforablation

    SBRT/SABRandalternativetechniquesofablation Reviewofunconventionalbrachytherapytechniques

    Image-guidedpercutaneoustechniques Stereotacticimplantation

    MinimallyinvasiveimplantationviaElectromagneticGuidance EMGuidedHDRforablativetreatmentoflunglesions

    Navigationandimplantation Dosecalculation Dosimetry relativetoSBRT/SABR

    Discussion Limitations Challenges Futuredirections

  • Fahimian,AAPM2017,Slide:4

    ConventionalApplicationsofBrachytherapy

    Wherearewe,andwherearewegoingwithclinicalapplicationsofbrachytherapy?

    ConventionalApplicationsofBrachytherapy

    Gynecological Genitourinary Breast

    Skin Ocular UnsealedSources

  • Fahimian,AAPM2017,Slide:5

    UnconventionalApplicationsofBrachytherapy

    Lessconventional techniques

    Brachytherapy islimitedbyimplantationaccess Newformsofminimallyinvasive implantationmaybethekeyforward

    Head&Neck Intracranial Endobronchial Intraoperative

    FocalTreatments ImageGuidedInterstitialImplantation Ablativedosing

  • Fahimian,AAPM2017,Slide:6

    ParadigmsforFocalandAblativeDelivery

    ExternalBeam SABR(SBRT) RoboticRadiosurgery

    Alternativetechniques RadiofrequencyAblation Cryoablation HIFU MicrowaveAblation Electroporation

    Nature Reviews Clinical Oncology 12, 175186 (2015)

    Cryoablation of Renal Tumors

  • Fahimian,AAPM2017,Slide:7

    AlternativeTechniques

    Biologicalmechanismofactiondifferentforthermalablationandradiotherapy DNAdamageviaionizingradiationvs.thermalablation(RFA,Microwave,Cryo)

    Courtesy of Lee et al., Transl Lung Cancer Res 2013;2(5):340-353

    Microwaveablationt=0 t=3months t=9months

  • Fahimian,AAPM2017,Slide:8

    StereotacticAblativeRadiotherapy(SABR/SBRT)

    Advantages Highlocalcontrolrate Non-invasive Accessanywhereinlung DoseconformalityChallenges Motionmanagement Potential forgeometricalmiss Substantial volumeoflungcanreceive lowerdoses Airwayandlungcollapse, radiationpneumonitis, lungfibrosis,orvertebral

    fracture

    SABR

  • Fahimian,AAPM2017,Slide:9 AAPM TG-76, 2006

    Tumor trajectories of 23 patients, using tracking of implanted fiducials. Seppenwoolde, et al., 2002

    RangeofTumorMotionforSBRTSites

  • Fahimian,AAPM2017,Slide:10

    Targetmotionisamajorcomplicatingfactor inSABR/SBRTdelivery Notethatimplantedseedsmovewithtarget

    Targetsmustnotonlybelocalizedinspacebutalsointime

    Videos of thoracic target motion. Courtesy of R. LiVideo

    MotionManagementforExternalBeam

    MotionManagementTechniques:

    Motion-encompassingirradiation

    Compression Breath-hold Gating Dynamictracking

    delivery

    TechnicalComplexity

  • Fahimian,AAPM2017,Slide:11

    BrachytherapyasanAblativeAdjuncttoSBRT

    Advantages Deliverablativedoses tolocalizedvolume Rapiddose fallofffornormal tissuesparing Motionmanagement issues reduced Enhanceddosimetry /higherablativedosesChallenges Access need forminimallyinvasive implantationtechniques Dependence onqualityofimplant Optimaldosingregimensneedfurther investigation

  • Fahimian,AAPM2017,Slide:12

    Image-GuidedPercutaneousTechniques

    ProspectivePhaseIItrial(Ricke,etal.) 30patientswith83singularlesions Meantumordiameterwas2.5cm(0.611cm).

    20Gy inasingleHDRfraction Singleapplicatorexcept2caseswith2 Adverseeffects:nausea(n=3,6%),minor(n=6,12%)andonemajorpneumothorax(2%)

    91%localcontrolat12months

    StrahlentherOnkol2008No.6

  • Fahimian,AAPM2017,Slide:13

    Image-GuidedPercutaneousTechniques

    Numberofsitesincludingliver,renal,lung,lymphnodes Surveyofinterstitialimage-guidedHDRofinnerorgans(Bretschneider,etal.,2016)

    Bretschneider,etal.,JournalofContemporaryBrachytherapy(2016/volume8/number3)

  • Fahimian,AAPM2017,Slide:14

    Image-GuidedPercutaneousTechniques

    Limitednumberofcatheters,1-3 Performedunderlocalanesthesia,conscioussedation Generallywelltolerated,limitedcomplicationsrelatingtocatheterinsertion CT,MRimagingwith3Dplanning

    Renal LymphNodes Lung(NSCLC) Liver

    Bretschneider,etal.,JournalofContemporaryBrachytherapy(2016/volume8/number3)

    Ricke,etal.,SeminRadiat Oncol,2011,21:287-293

  • Fahimian,AAPM2017,Slide:15

    Image-GuidedPercutaneousTechniques

    CTGuidedPlanning MRGuidedPlanning

    ImagesCourtesyofBretschneider,etal.,JournalofContemporaryBrachytherapy(2016/volume8/number3)

  • Fahimian,AAPM2017,Slide:16

    FramelessStereotacticImplantationofHeadandNeckLesions

    Pappas et al., Med Phys. 2005 32:6,1796-1801 Bane, et al., Radiology 2000; 591-595

  • Fahimian,AAPM2017,Slide:17

    Individualized3D-PrintedTemplatesforHeadandNeckBrachytherapy

    Huang,etal.:25HNpatientsimplantedwithI-125seeds Entrancedeviationfor619needleswas1.180.81mm

    Huang, et al., Journal of Radiation Research, Vol. 57, No. 6, 2016, pp. 662667

  • Fahimian,AAPM2017,Slide:18

    EstablishedLungBrachytherapyTechniques

    Palliationofairwayconstriction,5-7.5Gy x3

    MinimallyinvasiveHDRviaopticalbronchoscopywithfluoroscopicverification

    Limited/noaccesstoperipherallesionsinlung

    Endobronchial Intraoperative Focal- PercutaneousVicryl Mesh

    Guidelines(1cmspacing)withseeds

    Emulatesclassicsplanarimplants

    RowsofI-125seedswith1cmspacing

    Limitedasanadjunctoptionforoperableportionofthepatientpopulation

    ReviewReference:Skowronek,JournalofContemporaryBrachytherapy7:4(2015)

    Accesslimitedbytargetlocation

    Percutaneousimageguidedtransplantation

    Commonfractionationof20Gy x1

  • Fahimian,AAPM2017,Slide:19

    Robotics-AssistedIntraoperativeApproaches

    CurrentRespiratoryMedicineReviews,2011,Vol.7,No.5

    Laparoscopic robotassistedseedimplantation

    Coupledwithelectromagneticnavigationtogobeyondvideoassistedmethods

  • Fahimian,AAPM2017,Slide:20

    OpticalBronchoscopyandEndoluminal Approaches

  • Fahimian,AAPM2017,Slide:21

    LimitationsofOpticalBronchoscopy

    Flexible opticalbronchoscopesrangeinsizeofouterdiameter2.8-6.9mm Providesaccess toprimaryandportions

    ofsecondarybronchus Ingeneral limitedornoaccess totertiary

    bronchusandbronchiole fortherapeuticscopes

    Navigationtotertiarybronchus,bronchiole,andperipheral lesionsrequiresuseofsmallerprobessuchaselectromagnetic transponders

    Flexiblebronchoscope

    Thinelectromagneticprobe

    Peripherallesion

  • Fahimian,AAPM2017,Slide:22

    ElectromagneticNavigationBronchoscopy SuperDimensionTM (Covidien) ENBsystem

    routinelyutilized Fiducial Placement BiopsyofPeripheralLesions

    Requirestheco-registereduseof ThoracicCTwithairwaysegmentation Opticalbronchoscopy InternalEMtransponderfornavigation

    (locatableguide)

    Schwarz, et al., CHEST 2006; 129:988994)

    Image: Courtesy of Covidien

  • Fahimian,AAPM2017,Slide:23

    ElectromagneticNavigationBronchoscopy

    Clinical experience inthediagnostic realm Recenttrialof56patients,Ozgul,etal., 2016

    Meanproceduretimewas20 11.5min. Meanregistrationerrorwas5.8 1.5mm. Meannavigationerrorwas1.2 0.5mm Well tolerated Pneumothoraxoccurredinonly1patient(1.7%)

    Larger studyof151patientsbyWilson,etal.,2007 3(1%)modbleeding,1(0.3%)hematoma

    1(0.3%)pneumonia

    Endosc Ultrasound.2016May-Jun;5(3):189195; JBronchol.2007;14:227-232

  • Fahimian,AAPM2017,Slide:24

    ElectromagneticNavigationBronchoscopy

    Locatableguide:internaltransponderfornavigation

    Sensor1:1inchbelowthesternalnotchSensors2,3:alongthemid-axillarylineattheeighthrib

    Transmissionfrequencies:2.5,3.0,3.5kHZ

    Externalsensorsusedtoaccountforrespiratorymotion

    BoardemitslowfrequencyEMenablingtrackingwithin~40x40x30cmbox

    Extendedworkingchannelcontaininglocatableguide

    ImageReference:S.Leongetal.,J.Thorac.Dis.,vol 4,pp173(2012)andCovidien

  • Fahimian,AAPM2017,Slide:25

    ElectromagneticNavigationBronchoscopy

    Co-registrationoflocatable guide,CT,andopticalbronchoscope

    Dr.DanielPinkham ExternalSensors

  • Fahimian,AAPM2017,Slide:26

    ElectromagneticNavigationBronchoscopy

    S.Leongetal.,J.Thorac.Dis.,vol 4,pp173(2012)

    360degree(8way)steering

  • Fahimian,AAPM2017,Slide:27

    Electromagnetic-GuidedHDRWorkflow

  • Fahimian,AAPM2017,Slide:28

    FirstProspectiveDemonstrationsEM-GuidedHDR

    Themajorityofpatients(7580%)withnon-smallcell lungcancer(NSCLC)arediagnosedwithadvancedinoperabledisease resulting

    Peripheral targetspresentdifficultiesforpercutaneousimplantation

    Electromagnetic NavigationBronchoscopyofasingle6Fcatheter,implantedwith CTbasedsegmentationoftheairway Endobronchial Ultrasound Fluoroscopicverification

    OneofthefirstdemonstrationsbyHarmsetal.in2006 15Gy in3fractions(over5days)after50Gy external beam CTbasedplanning Catheterremaining inplace forthefractionatedtreatments

    CTverificationshowed

  • Fahimian,AAPM2017,Slide:29

    CanEM-GuidedHDRProvideanAlternativetoSABR?

    RetrospectivestudyPatientsformerlytreatedwithSABR(n=10)

    Previouslytreatedto50GywithSABR CT-visibleairwayadjacenttoGTV GTVrangingfrom1.5ccto20cc

    Replanned usingsinglecatheterHDRtreatment Plannin