State of the art radiotherapy day by BIR Publishing

10 DECEMBER 2014

STATE OF THE ART RADIOTHERAPY EDUCATION DAY Venue: Stewart House, London CPD: 5 CREDITS

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON

Day 1 Primers for the nonspecialists • Room 1

Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

Session organised by Dr Richard Wakefield, Consultant in Rheumatology, St James’s University Hospital

Radiation protection

Musculoskeletal imaging

Essentials for the radiology trainee More information available soon at www.bir.org.uk

Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital, and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to our ‘State of the art radiotherapy education day’ organised by the British Institute of Radiology. We wish you a very enjoyable and educational experience. Certificate of attendance This meeting has been awarded 5 RCR category I CPD credits. Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/Radiotherapyeducationday

BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference. Please take the time to visit their exhibition stands to find out more about the services they offer. 1

Programme

09:15 Registration and refreshments 09:40 Welcome and introduction Mrs Nicola Blackler Lead Dosimetrist Planning and Trials, Derriford Hospital 09:45

Setting up the treatment unit: intelligence-guided QC Mr Geoff Budgell Team Leader for Verification and Dosimetry, The Christie NHS Foundation Trust

10:15 Imaging in radiotherapy: current options available Dr Tim Wood Clinical Scientist, Hull and East Yorkshire Hospitals NHS Trust 10:45 Refreshments 11:15 Chemotherapy: principles and new developments Dr Martin Highley Consultant Oncologist, Plymouth Oncology Centre, Derriford Hospital 11:40

Target volume definition Mr Jamie Fairfoul Head of Radiotherapy Planning, Peterborough and Stamford Hospitals NHS Foundation Trust

12:05

SABR gating and 4DCT Mr Andrew Poynter Consultant Clinical Scientist and Head of Radiotherapy Physics, Peterborough and Stamford Hospitals NHS Foundation Trust

12:30 Lunch 13:30 Basic and advanced treatment planning Ms Hayley James Head of Radiotherapy Physics, Ipswich Hospital 14:00

Verification of advanced treatment techniques Mr Geoff Budgell Team Leader for Verification and Dosimetry, The Christie NHS Foundation Trust

14:30 On set imaging: from 2D to 3D and beyond Mr Andrew Reilly Consultant Clinical Scientist, Clatterbridge Cancer Centre 2

15:00 Refreshments 15:30

Radiobiologic modelling in gynaecologic cancer Dr Alexandra Stewart Consultant Clinical Oncologist, Royal Surrey County Hospital NHS Foundation Trust

15:50 Flattening filter free (FFF) Mr Chris Walker Head of Radiotherapy Physics, The James Cook University Hospital 16:10

Proton radiotherapy Mr Richard Amos Operational Lead for Proton Beam Therapy Physics, University College London Hospitals NHS Foundation Trust

16:30 Questions 16:45 Close of event _______________________________________________________________________

Certificate of attendance This meeting has been awarded 5 RCR category I CPD credits. Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/Radiotherapyeducationday

BIR Annual Congress 2015: 4â&#x20AC;&#x201C;5 November, London

Speaker profiles (where supplied) Mr Richard Amos Operational Lead for Proton Beam Therapy Physics, University College London Hospitals NHS Foundation Trust Richard Amos is Operational Lead for Proton Beam Therapy Physics at University College London (UCL) Hospitals NHS Foundation Trust and Honorary Senior Lecturer at the Department of Medical Physics and Biomedical Engineering at UCL. Prior to taking up his current position in 2013 Richard gained over twelve years experience in proton beam therapy physics at both Loma Linda University Medical Center and University of Texas MD Anderson Cancer Center in the USA. His current research interest is in the development and clinical implementation of advanced proton beam therapy (PBT) technology for the treatment of cancer. UCL Hospitals are developing one of the two first high-energy PBT facilities in the UK to serve jointly as a national PBT service, due to commence treatment in 2018. Richard is a Fellow of the Institute of Physics and Engineering in Medicine, and serves on a number of professional committees in both the UK and USA. Mrs Nicola Blackler Lead Dosimetrist Planning and Trials, Derriford Hospital Nicola Blackler started working in the NHS in 1989 as a trainee medical physics technician and on qualification specialised in radiotherapy physics. In 2005 she achieved her MSc in radiotherapy studies and currently works as Head of Treatment Planning and Mould Room within the Directorate of Healthcare Science and Technology at Plymouth. She is now the joint vice chair of the BIR Radiotherapy and Oncology Special Interest Group. Mr Geoff Budgell Team Leader for Verification and Dosimetry, The Christie NHS Foundation Trust Geoff Budgell is Team Leader for Verification and Dosimetry at the Christie NHS Foundation Trust. He spent four years in a research role developing IMRT in its early days, including the first delivery of IMRT in the UK, before moving into a more clinical role. Geoffâ&#x20AC;&#x2122;s research interests centre on the delivery and verification of modern complex radiotherapy techniques and the adaptation of radiotherapy imaging systems for quality control and verification purposes. He is particularly keen on putting the results of research to practical purposes which has resulted in the introduction of new and more efficient radiotherapy quality control methods. More recently he has been involved in setting up two satellite centres, introducing large-scale use of VMAT at the Christie, setting up a QC program for FFF beams and is starting to work on QA aspects of the MR linac.

Mr Jamie Fairfoul Head of Radiotherapy Planning, Peterborough and Stamford Hospitals NHS Foundation Trust Jamie Fairfoul is Head of Treatment Planning at Peterborough City Hospital, a small but very busy department with extensive experience of advanced IMRT and IGRT. Dr Martin Highley Consultant Oncologist, Plymouth Oncology Centre, Derriford Hospital Martin Highley is a Consultant Medical Oncologist at Derriford Hospital, Plymouth, managing patients with melanoma, renal cell carcinoma, and ovarian and testicular cancers. He trained at Guys Hospital, London and The Northern Centre for Cancer Treatment, Newcastle. He has an interest in the pharmacology of anti-cancer agents. Ms Hayley James Head of Radiotherapy Physics, Ipswich Hospital Hayley James has been a physicist at Ipswich Hospital since 1999, having trained previously at Sheffield and then worked as a radiotherapy physicist at the Christie. She has been Head of Radiotherapy Physics at Ipswich Hospital since 2010. She has always had particular interests in implementing new technologies, such as IMRT and VMAT and more recently SABR, as well as radiotherapy clinical trials. She is a member of the NPL Radiation Dosimetry Steering Group, IMPORT Trial Management Group and attends RT Trials QA management group meetings. Mr Andrew Reilly Consultant Clinical Scientist, Clatterbridge Cancer Centre Andrew Reilly is a Consultant Clinical Scientist in the radiotherapy physics department at the Clatterbridge Cancer Centre. His primary role is to support the clinical use and development of radiotherapy imaging technologies and work towards improved systems integration. He has a particular interest in bridging the gap between different imaging disciplines and optimising imaging across the radiotherapy process. He is founder of the IQWorks project, leads the Radiotherapy Imaging User Group and provided physics support under the national NRIG mentoring programme for IGRT implementation. Andrew served as Chairman of the BIR Radiation, Physics and Dosimetry Committee until 2009, was a member of BIR Council from 2010 to 2013 and represents the BIR on the DH Medical Physics Expert working group.

Dr Alexandra Stewart Consultant Clinical Oncologist, Royal Surrey County Hospital NHS Foundation Trust Alex Stewart went to medical school at Southampton University. She developed an initial interest in oncology at the Royal Marsden Hospital working on primary prevention of breast cancer studies in the Professorial unit. She then commenced specialist registrar training at Charing Cross and the Hammersmith Hospitals where amongst other interests she gained initial experience in brachytherapy. She was then chosen for a prestigious Fellowship at the Brigham and Womenâ&#x20AC;&#x2122;s Hospital, Harvard University in Boston where she completed a year of brachytherapy training and a year of prostate cancer Fellowship on a National Institute of Health grant. Whilst there she won an ASCO merit award for a prostate cancer study that was subsequently published in the Journal of Clinical Oncology. She returned from the USA to complete her specialist registrar training at the Royal Marsden Hospital where she continued to publish on specialist radiotherapy techniques such as IMRT in lower limb sarcomas. On completing her specialist training she chose to work in Guildford owing to the exemplary brachytherapy department they had. Alex has now developed their cervix brachytherapy and added oesophageal and rectal brachytherapy to the portfolio, one of few international centres to perform this. Alex has a strong interest in the clinical applications of radiobiology in brachytherapy and has written three textbook chapters on this subject, in addition to published papers. Alex has kept her research links strong, holding an honorary contract at the University of Surrey as a Visiting Professor. She is leading a study on cervix IMRT and another on the use of PET scanning in early cervix cancer. She is also developing improved imaging techniques in cervix brachytherapy and collaborating with the university physics and engineering departments in innovative projects. Since starting at the Royal Surrey in 2008, Alex has taken a keen interest in management, taking on the role of Radiotherapy Lead in 2010 and becoming Clinical Director for the Oncology, Medical Physics and Nuclear Medicine Directorate in 2012. She is now Clinical Lead for Oncology. Mr Chris Walker Head of Radiotherapy Physics, The James Cook University Hospital Chris Walker started his career in medical physics in 1987 employed by the Regional Medical Physics Department as a basic grade radiotherapy physicist at Newcastle General Hospital. He is presently a Consultant Clinical Scientist and Head of Radiotherapy Physics at The James Cook University Hospital in Middlesbrough. He has a wealth of experience both in the UK and abroad in the development and delivery of radiotherapy from the ground up. He has provided strategic advice and support at home and overseas to health departments, radiotherapy departments and private companies. In 2011 he was formally elected as chair of the North of England Cancer Network Radiotherapy Cross Cutting Group (CCG), which has responsibility for the development of coordinated, cohesive and integrated networked cancer services for radiotherapy. Additionally he is the North East senate representative on the Radiotherapy Clinical Reference Group.

Dr Tim Wood Clinical Scientist, Hull and East Yorkshire Hospitals NHS Trust Tim Wood works as a Radiation Protection and Diagnostic Imaging Physicist in the Radiation Physics Department, Hull and East Yorkshire Hospitals NHS Trust, and is also a current member of the IPEM Diagnostic Radiology Special Interest Group. Tim is currently leading a number of projects investigating the development, implementation and optimisation of X-ray imaging techniques in radiotherapy. Other interests include the physics, technology and clinical application of CT and digital X-ray imaging, including mammography.

Abstracts (where supplied) Setting up the treatment unit: intelligence-guided QC Mr Geoff Budgell Quality control is often considered a dull necessity, preferably left to someone else to do. The aim of this talk is to demonstrate that, if your brain is engaged, QC can be interesting. It will also show how QC needs to be constantly adapting to the ever-changing challenges of radiotherapy including new technologies (such as IGRT, FFF, stereotactic treatments and MR linacs) as well as on-going clinical demands on the service such as extended working hours, in vivo dosimetry and patient-specific verification for complex treatments. The presentation will address the questions: • How do we decide what QC to do? • How do we decide on tolerances and frequencies for QC tests? • Do we have to follow reports and recommendations? • What do you do when implementing a new technique or piece of equipment? • Who should do QC? • What to do when a QC test is out of tolerance? • When should QC be carried out and how do we cope with increasing complexity of equipment without increasing the time taken for QC? • How does QC relate to clinical practice and evidence? Imaging in radiotherapy: current options available Dr Tim Wood Imaging plays a fundamental role at all stages of the patient pathway in a state-of-the-art radiotherapy centre, be it the initial diagnosis, treatment planning scans or verification imaging. For this reason, the use of ‘image guided radiotherapy’ should now be considered to be the standard of care for all treatments, rather than a limited specialist application. However, there are many options available for acquiring image data that can inform decisions regarding an individual patient’s treatment, with each modality having specific advantages and disadvantages. It is therefore important to understand how each imaging technique works to ensure the best possible outcome for the patient. The purpose of this talk is to outline the various imaging options that are currently available in the state-of-the-art radiotherapy centre. These include, but are not limited to, CT, cone beam CT, PET–CT, MRI and ultrasound. A brief overview of the principles and benefits of each technique will be presented, along with a range of issues that should be considered when implementing these technologies. Learning objective: Acquire an understanding of the current options for imaging in radiotherapy, and the advantages and disadvantages of each technique. 8

Chemotherapy: principles and new developments Dr Martin Highley Chemotherapeutic agents have been used to treat cancer since 1946. They act by interfering with cell division, primarily by affecting DNA replication. They are classified into five groups; alkylating agents, platinum compounds, antimetabolites, topoisomerase interacting agents and antimicrotubule agents. The inhibition of rapidly dividing cells can lead to the development of particular toxicities, such as bone marrow suppression, stomatitis, diarrhoea and alopecia. The use of chemotherapeutic agents needs to be balanced against their toxicities. Chemotherapy, like radiotherapy, is used in different setting—neoadjuvant (prior to surgery), adjuvant (after surgery) and in the treatment of metastatic disease. The assessment of response is important when using anti-cancer treatments, and the RECIST criteria are widely employed to assess radiological response. Other indicators of the effectiveness of chemotherapy are the survival of patients and the time to the development of progressive disease. The effect on quality of life is frequently evaluated. Clinical trials are a significant aspect of the use and development of systemic treatments. Systemic treatment has changed immensely in the 21st century with the introduction of targeted therapies. These comprise two main groups: the small molecules, which inhibit signal transduction, and the immunotherapies. Learning objective: To understand the mechanisms of action, clinical use and toxicities of the classical chemotherapeutic agents and the newer targeted agents and immunotherapies. Target volume definition Mr Jamie Fairfoul Good target volume definition (TVD) is the foundation on which accurate radiotherapy is built. Without accurate target outlines, the precision afforded by modern IMRT and IGRT cannot be fully utilised. Although this talk cannot hope to cover the intricacies of TVD for all clinical sites, it will explain the key principles of good practice that should be used for all contouring. Learning objectives: •

Accuracy in contouring • Why is it important? • Impact on treatment quality

•

Optimising your materials/environment

•

Optimal imaging for TVD 9

•

Use of multi modality imaging/image fusion • Appropriate choice of imaging modality • Accuracy of additional imaging techniques • Assessing image registration

•

Consistency: how do we measure it and how do we achieve it? • What is the correct answer? • The importance of outlining protocols?

Basic and advanced treatment planning Ms Hayley James The radiotherapy treatment planning process determines the most appropriate way of irradiating a patient to meet the clinical requirements of the treatment. Creating optimal treatment plans for a given clinical site relies on a number of processes that include: • Determination of patient position and suitable immobilisation • Accurate target volume and organ at risk localisation and delineation • Determination of suitable beam arrangements (forward planning) or the required dose and dose volume constraints (inverse planning) • Accurate dose modelling and dose computation methods • Evaluation of dose distributions • Determination of the required treatment machine settings to deliver the resultant plan This talk will concentrate on the fundamentals of forward and inverse planning in relation to 3D conformal radiotherapy, IMRT and VMAT. Consideration will be given to beam and fluence shaping, plan optimisation, dose calculation and dose evaluation. Methods of beam modelling and dose computation will also be discussed. Verification of advanced treatment techniques Mr Geoff Budgell Over the last few years, the use of advanced radiotherapy techniques such as IMRT, VMAT and SABR has mushroomed in the UK. The increased complexity of the techniques has led to the adoption of patient-specific verifications on a large scale. This talk will consider what verification is actually for, look at the measurement options available and describe the analysis methods commonly used. Pitfalls in making and analysing measurements will be identified and advice given on selecting tolerances. As numbers increase, and as adaptive planning becomes a clinical reality, many departments are asking whether patient-specific verifications are required for every treatment plan. This question will be addressed, identifying how we can safely move away from patient-specific measurements and what systems have to be in place to allow this to be carried out. 10

On set imaging: from 2D to 3D and beyond Mr Andrew Reilly Treatment planning is only the start of the radiotherapy patientâ&#x20AC;&#x2122;s journey. Although a great deal of effort is expended developing the optimum plan tailored to the individual patientâ&#x20AC;&#x2122;s circumstances, it is important that the plan be consistently delivered as intended over the subsequent course of treatment: whether during a single fraction or over many weeks. Verification imaging at the point of treatment is an important tool for ensuring safe and consistent radiotherapy delivery over time. This presentation explores the imaging capabilities of modern radiotherapy treatment units, tracking the evolution from 2D planar MV and kV imaging through 3D cone-beam CT (CBCT) volumetric imaging, 2D/3D hybrid imaging and 4D CBCT. Advanced applications beyond basic verification imaging are also considered including strategies for plan adaptation and in vivo dosimetry using electronic portal imaging devices (EPIDs). The potential of emerging technologies such as implanted radio-transponders and real-time tracking is discussed. When working with state of the art technology, and particularly technology involving automation and advanced computer systems, it is important to maintain focus on the clinical endpoint and avoid becoming distracted by the IT. Methods for ensuring technology is utilised as effectively as possible are considered, including optimisation of imaging protocols, peer review through multi-centre audit and automatic calculation of setup errors and margins. Radiobiologic modelling in gynaecologic cancer Dr Alexandra Stewart Historically brachytherapy doses were developed empirically, changing doses (duration of implant) according to tumour response, early and late toxicity. In this way low dose rate (LDR) brachytherapy doses were established. Dose prescription was established to fixed geometric points in the 1930s and due to their effectiveness were changed very little for over 70 years. Normal tissue toxicity was predicted by using ICRU reference points, again without reference to actual organ location. The advent of high dose rate (HDR) brachytherapy emphasised the importance of radiobiology in gynaecologic cancer, with use of radiobiologic modelling to convert doses from LDR to HDR and to predict toxicity. Due to unavailability of radioactive sources, LDR use has declined and been replaced by HDR or pulsed brachytherapy (PB). Again radiobiologic modelling has been critical in PB to determine what doses are required given duration of pulse and interval between pulses. Gynaecologic brachytherapy has now developed from point dosing to volume based prescription. This allows radiobiology to be used to accurately determine 11

the doses administered to tumour and normal tissues and has resulted in greater rates of local control and thus cure with lower late toxicity. This presentation will examine basic radiobiologic principles and show how they have been used to develop modern gynaecologic brachytherapy. Flattening filter free (FFF) Mr Chris Walker This presentation explores the clinical implementation of flattening filter free (FFF) technology in Middlesbrough with the Elekta linear accelerator. Delegates will get an insight into what is required to convert a conventional linac to utilise FFF technology. The Elekta implementation philosophy will be contrasted with that of Varian and the difference between clinical beams of the same notional energy from the two manufacturers will be explained. Radiation safety will be discussed in relation to the significantly higher instantaneous dose rates achieved with these radiation beams. Once FFF has been enabled the commissioning process will be explored with particular emphasis on the absolute dose calibration methodology. This is of particular importance as presently a UK code of practice for reference dosimetry on these beams is still under development. In order to confirm the long term validity of the commissioning process baseline quality control parameters were established and will be demonstrated in this presentation. Throughout the presentation the potential advantages of this technology in the clinical environment will be discussed including the reduction of head scatter and the enhanced dose rate. Examples of clinical plans will be presented with dose distributions for SABR for non-small-cell lung cancer, hypofractionated prostate treatments and intracranial stereotactic treatments for brain metastasis. Data on treatment delivery times will also be provided to demonstrate the intrinsic efficiency of this technology. Finally the impact that this technology potentially exhibits in treatment of left sided breast cancer, under deep inspiration breath hold will be demonstrated. Proton radiotherapy Mr Richard Amos Proton radiotherapy potentially offers clinical advantages over conventional radiotherapy owing to the physical characteristics of charged particle interaction. As protons traverse patient anatomy they lose energy, slowing down and becoming more densely ionising as they approach their end-of-range, at which point they stop. This manifests into dose deposition as a function of depth that increases to a maximum, the Bragg peak, towards their end-of-range, with no dose beyond. By choosing proton beams of initial energy such that the Bragg peak region is delivered at the depth of the clinical target volume (CTV), the therapeutic dose can be realized with reduced dose to surrounding healthy tissue compared with that delivered by photons. Reduced dose to surrounding tissue offers the potential for reduced acute toxicity and secondary cancer risk. 12

Current state-of-the-art technological requirements for the provision of proton radiotherapy are large scale and expensive. Despite this, however, the promise of a clinical advantage has led to a rapid growth in availability of proton beam facilities worldwide in recent years, and such technology will soon be available in England for NHS patients indicated for protons. The educational aims of this presentation are to introduce the audience to the fundamental characteristics of clinical proton beams; to describe the technology and layout of a typical proton facility; to provide examples of delivered treatments; and to summarise the UK project to date. The learning objective will be an understanding of the rationale for proton radiotherapy; the technological requirements; and future of proton radiotherapy in the UK.

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