Stereotactic ablative body radiotherapy: Current status and developments by BIR Publishing

Stereotactic ablative body radiotherapy: Current status and developments Registered Charity No: 215869

12 December 2013 Venue: Stewart House, The London Deanery 5 CPD credits

Welcome and thank you for coming to the â&#x20AC;&#x2DC;Stereotactic ablative body radiotherapy: Current status and developmentsâ&#x20AC;&#x2122; event organised by the British Institute of Radiology. This booklet contains the abstracts and biographies for each speaker (where supplied). This meeting has been awarded 5 RCR category I CPD credits. CPD certificates will be distributed by email within 2 weeks of the meeting after the online delegate survey has been completed. Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/SABR_12Dec We hope you find the day interesting and enjoyable. Nicola Blackler and Andy Beavis Meeting Organisers Radiotherapy Physics SIG, BIR

We are most grateful to

for supporting this conference

Programme 09:00

09:45

Registration and refreshments Welcome

10:00 The principals and clinical evidence for SABR in different sites Dr Kevin Franks, Consultant Clinical Oncologist, St James’s Institute of Oncology 10:30

11:00

The comissioning process of SABR Dr Gareth Webster, Medical Physicist, University Hospitals Birmingham Physics and quality assurance Mr Neil Richmond, Clinical Scientist, The James Cook University Hospital

11:30 Proffered paper 1: Results of patient specific plan QA of NSCLC SABR with QUASAR anthropomorphic body phantom and MAPCHECK2 diode array Ms Vanya Staykova, Radiotherapy Physicist, Northampton General Hospital NHS Trust 11:42 Manufacturer’s viewpoint Mr David James, Sales Manager Radiosurgery, Varian Medical Systems 11:57 Manufacturer’s viewpoint Mr Barry Bonner, Regional Sales Director, Accuray 12:12 Manufacturer’s viewpoint Mr Amiya Roy, Business Line Manager - Stereotactic Solutions, Elekta 12:27

Questions

12:30

Lunch

13:30 4D-CT scanning and the SABR planning process Dr Simon Meara, Radiotherapy Physicist, The Clatterbridge Cancer Centre 14:00

Proffered paper 2: A review of challenging SABR lung cases Ms Gail Distefano, Principal Clinical Scientist, Royal Surrey County Hospital

14:12 Proffered paper 3: Evaluation of cyberknife prostate plans developed with 2 different template path techniques Mr Prasanasarathy Nariyangadu, Radiotherapy Physicist, Mount Vernon Cancer Centre

14:24 Proffered paper 4: A smarter way of planning SABR lungs Mr Tom Williams, Trainee Medical Physicist, The Clatterbridge Cancer Centre 14:36 Proffered paper 5: Using lung optimized treatment and monte carlo plan evaluation for treating lung lesions with a cyberknife Dr Melvyn Folkard, Clinical Scientist, Mount Vernon Cancer Centre 14:48 Verification and treatment delivery: SABR from the radiographerâ&#x20AC;&#x2122;s point of view Mrs Marianne Dabbs, Radiotherapy Practise Development Manager, Royal Surrey County Hospital 15:20

Refreshments

15:45 Proferred paper 6: Online CBCT verification for SABR Mrs Nazima Haji, Technical Lead/Systems Admin, University College London Hospital Foundation Trust 15:57 Proffered paper 7: Imaging dose during cyberknife treatments Miss Philippa Sturt, Radiotherapy Physicist, Mount Vernon Cancer Centre 16:09 Proffered paper 8: Liver stereotactic body radiation therapy (SBRT) for metastatic liver disease: initial UK experience Dr Katharine Aitken, Clinical Research Fellow, The Royal Marsden NHS Foundation Trust 16:21 Proffered paper 9: Experiences of the UK SABR consortium mentoring programme Ms Karen Whitfield, Clinical Scientist, Bristol Haematology and Oncology Centre 16:33 Proffered paper 10: Paperlite SABR Ms Suzanne Jordan, Radiographer, Nottingham Radiotherapy Centre 16:45

Questions

16:50

Close of meeting

Please remember to complete the online delegate survey using the below link. https://www.surveymonkey.com/s/SABR_12Dec Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

Speaker profiles (where supplied) Dr Katharine Aitken, Clinical Research Fellow, The Royal Marsden NHS Foundation Trust Katharine Aitken is a Clinical Research Fellow at The Royal Marsden Hospital. Her area of research is the utility of SBRT for the treatment of oligometastatic disease. She is studying for an MD (Res) under the supervision of Professor Chris Nutting and Dr Maria Hawkins. She is also interested in lung and GI cancers. Mr Barry Bonner, Regional Sales Director, Accuray Barry Bonner is the Regional Director for Accuray in the UK & Ireland, having worked within the Radiotherapy industry for the last 11 years, specialising in Brachytherapy, imaging, SABR/SRS and IG-IMRT. Accuray is a global leader in the field of Radiosurgery, dedicated to providing improved quality of life and a non-surgical treatment option for patients diagnosed with cancer. Accuray develops the CyberKnife®Robotic Radiosurgery System and TomoTherapy® IG-IMRT System. Mrs Marianne Dabbs, Radiotherapy Practice Development Manager, Royal Surrey County Hospital Marianne Dabbs trained at Liverpool University qualifying in 1997, working predominately in the treatment area for the first 5 years of her career. She joined the team at St Luke’s Cancer Centre, Royal Surrey County Hospital in 2002, then moved into the position of Radiotherapy Research Radiographer in 2008 successfully leading and developing the radiotherapy trials porfolio for 2 and a half years. In 2010 Marianne took on her current role as the Radiotherapy Practice Development Manager overseeing the introduction of developments such as SABR-Lung, and Deep inspiration breathhold for breast patients. She also manages the educational strategy of the department, for both qualified staff and the undergraduates within the department. Marianne is currently studying for her MSc in Professional Practice at the University of Surrey. Ms Gail Distefano, Principal Clinical Scientist, Royal Surrey County Hospital Gail Distefano moved to the UK in 2001 to read an MSc in Medical Physics at the University of Aberdeen, which she completed in 2002. She worked at Clatterbridge Cancer Centre (2003-2010), where she implemented and supported national clinical trials. In 2010 she took up a senior radiotherapy physicist post at the Royal Surrey County Hospital where she developed a SABR RapidArc planning protocol. Her continued interest in SABR led to her becoming co-chair of the UK SABR Consortium QA sub-group. Recently Gail has taken up a role as Deputy Head of Brachytherapy.

Dr Melvyn Folkard, Clinical Scientist, Mount Vernon Cancer Centre After obtaining a PhD in Radiation Physics, Dr Folkard spent over 20 years in radiobiology research at the Gray Cancer Institute. His work included the development of novel radiation delivery systems (microbeams) that could micro irradiate individual living cells with micrometre precision. These facilities were used in pioneering studies of the so-called ‘bystander effect’. In 2007, Dr Folkard moved to the Mount Vernon Cancer Centre, where he is now a Clinical Scientist in the Radiotherapy Physics department, leading the QA and Dosimetry Group. In 2010, he was substantially involved in the commissioning of department’s CyberKnife and continues to provide physics support for this facility. In 2011, he initiated (and currently Chairs) the UK CyberKnife interdepartmental audit group. Dr Kevin Franks, Consultant Clinical Oncologist, St James’s Institute of Oncology Dr Kevin Franks is a Consultant Clinical Oncologist at the St James’s Institute of Oncology at the Leeds Cancer Centre with a specialist interest in technical radiotherapy particularly stereotactic ablative radiotherapy and image guided radiotherapy and brachytherapy. Prior to his current post he was a clinical research fellow at Princess Margaret Hospital, Toronto under the supervision of Professors Andrea Bezjak, David Jaffray and Laura Dawson performing SABR research. He was co-chair of the NRIG/NCAT national Image-Guided Radiotherapy guidelines and a member of the UK SABR consortium executive, CTRAD and the clinical lead for the Leeds Lung SABR programme. Current research interests/projects include SABR, IGRT, 4DCT and prostate brachytherapy. He is the chief investigator on the proposed “Surgery versus SABR for patients with stage I NSCLC considered at higher risk from surgical resection (submitted to RFPB Sept 2013), a co-investigator on the proposed SARON trial (a SABR trial for treatment of oligometastases in non-small cell lung cancer NSCLC), the funded ISOTOXIC IMRT lung and eRAPID studies. Mrs Nazima Haji, Technical Lead/Systems Admin, University College London Hospital Foundation Trust Nazima qualified as a Therapy Radiographer in 1997 from City University and completed an MSc in Oncology soon after in 2001. Nazima has worked clinically in all areas of Radiotherapy and joined UCH in 2001. In 2008 Nazima took on the role of Technical Development and Treatment Floor Lead Radiographer. The Radiotherapy Department at UCH is at the cutting front of technology and as part of her role Nazima has played a pivotal role in the development and implementation on new techniques and technology within the department e.g. IMRT and RA for a range of treatment sites, use of CBCT for on treatment verification, supine CNS treatment delivery, the clinical use of the first UK Truebeam STx and setting up a SABR programme using RA delivery. Her expertise has allowed her to lead a number of service developments and changes to practise which has enhanced the quality of service provided to patients undergoing radiotherapy at UCH.

Mr David James, Sales Manager Radiosurgery, Varian Medical Systems David James joined Varian Medical Systems in September 2011 following 13 years with Brainlab where he was Product Manager for the ExacTac patient positioning system and subsequently Sales Manager for the UK. During this time he was closely involved in the development of the Novalis Radiosurgery programme and its subsequent introduction and clinical implementation in the Clatterbridge Centre for Oncology, The Christie in Manchester and the Western General Hospital in Edinburgh. Within Varian he builds on his experience of frameless stereotactic radiosurgery / SBRT and is responsible for the EDGE and TrueBeam STx Radiosurgery platforms as well as the Calypso real-time tracking system which will be described in his presentation. Ms Suzanne Jordan Radiographer, Nottingham Radiotherapy Centre After qualifying as a Radiographer I worked in several departments in the U.K. and in New Zealand before returning to Nottingham in 2001. I started in Nottingham as a Treatment Radiographer and always had an interest in imaging and the verification process. By keeping abreast of the developments in radiotherapy imaging and after completing an imaging module through Sheffield Hallam University, I got a position as an Advanced Practitioner in Image Review. This post covers a variety of areas including developing the imaging service, staff training and competency maintenance, audit of imaging data and protocol maintenance. I have also attended IGRT anatomy courses and 4D IGRT for IMRT courses through Elekta and Sheffield Hallam that have complimented my practical experience within the department. My next project will be introducing the Clarity ultrasound system for phase 2 breast boosts. Dr Simon Meara, Radiotherapy Physicist, The Clatterbridge Cancer Centre After graduating from the University of Cambridge in 1995 with an MA degree in Physics and Theoretical Physics, Simon Meara commenced employment as a Trainee Clinical Scientist at Addenbrookeâ&#x20AC;&#x2122;s Hospital in Cambridge. He completed the Grade A Training Scheme of the Institute of Physics and Engineering in Medicine, while also studying part time for an MSc degree at University College London. In 1998, Simon moved to the Institute of Psychiatry in London, where he worked for the next 7 and a half years. His initial appointment was as a Research Associate, during which time he studied part time for a PhD degree in magnetic resonance image analysis, before taking up a position as a Post-Doctoral Research Worker. Simon relocated to the University of Manchester in 2006, where he worked for two years as a Research Fellow. In April 2008, Simon took the decision to return to hospital-based medical physics, and he was appointed to a position of Radiotherapy Physicist at The Clatterbridge Cancer Centre (CCC). He is the lead physicist for 4D-CT and gating at CCC, and has also recently assumed the role of lead SABR lung physicist.

Mr Prasanasarathy Nariyangadu Radiotherapy Physicist, Mount Vernon Cancer Centre Prasana Nariyangadu was born in a metropolitan city in southern India. After completing a postgraduate degree in medical physics at Anna University (India), in 2005, Prasana served as a Medical Physicist at several hospitals in India. In 2009, Prasana was awarded a fellowship to work for one month at the Indiana School of Medicine (USA), on non-coplanar IMRT planning for pancreatic cancers. In 2010, Prasana moved to the UK to work at the Mount Vernon Cancer Centre, primarily providing physics support for their CyberKnife. Dr Neil Richmond, Clinical Scientist, The James Cook University Hospital Neil Richmond is a registered Clinical Scientist since 2000 and has been working at the James Cook University Hospital since 2004. He was part of the multi-disciplinary team leading to the implementation of lung SBRT treatments in Middlesbrough in the Autumn of 2009. He was also a member of the National SBRT NRIG subgroup which published the “Guidelines for Commissioners, Providers and Clinicians in England 2011”. Mr Amiya Roy, Business Line Manager - Stereotactic Solutions, Elekta After earning a Bachelor’s and a Master’s Degree in Electrical Engineering, Mr Roy emigrated to the USA in 1990 with his wife, also an engineer and raised a daughter and a son in St. Louis. Both his children chose to pursue the medical profession to become physicians. Mr Roy is an experienced Radiation Therapy professional with over 24 years of experience in Radiation Therapy Sales, Marketing, and Business Line Management. Born, brought up, and educated in India, he has spent most of his working career in the US and has now been living in the UK for the past 2 years. His career in radiotherapy spans 11 years with Multidata Systems – a small privately held Radiation Therapy dosimetry and Accessory company, and 13 years with Elekta.

Ms Vanya Staykova, Radotherapy Physicist, Northampton General Hospital NHS Trust Vanya Staykova is a Medical Physics Professional in Radiation Therapy and has been working for more than fifteen years in Radiotherapy Departments at Bulgarian National Centre of Oncology, University Hospital Queen GiovannaSofia and currently at Northampton General Hospital NHS Trust. She has started her career as Research Physicist in Radiation Dosimetry at SSDL. Vanya has a Masters Degree in Nuclear and High Energy Physics from Sofia University ‘St. Kliment Ohridski’ and postgraduate education and training in Medical Radiological Physics from Medical University, Sofia. Vanya has extensive experience in routine treatment planning and machine QA. Vanya has been involved in the clinical implementation of Advanced Radiation Therapy techniques as well as IAEA Technical Cooperation and Coordinated Research Projects. Vanya’s recent work has focused on IMRT and SABR implementation at NGH NHS Trust. Miss Philippa Sturt, Radiotherapy Physicist, Mount Vernon Cancer Centre I studied Physics with Medical Physics at the University of Sheffield and went on from there to join the IPEM Clinical Scientist training scheme in September 2009. I spent the first two years of my training at King’s College Hospital, London, completing an MSc in Medical Engineering and Physics and a series of hospital placements. I spent three months in the radiotherapy department at Guy’s and St Thomas’s hospital. In October 2011 I started work in the radiotherapy department at Mount Vernon Cancer Centre, Northwood, where I currently work and have just submitted my portfolio for state registration as a Clinical Scientist. During my time at MVCC I have been involved in commissioning two Varian TrueBeam linacs and clinical implementation of the AAA dose calculation algorithm. Dr Gareth Webster, Medical Physicist, University Hospitals Birmingham Gareth Webster is a Clinical Scientist working at University Hospital Birmingham with particular interests in adaptive radiotherapy, functional imaging and SABR. Following completion of a PhD in H&N IMRT, he assisted in the implementation of 4DCT and lung SABR at the Christie Hospital, before joining the Medical Physics department at Birmingham in 2012 and managing the local implementation of lung SABR. He is a member of the Executive Committee of the UK SABR Consortium, Chair of the Guidelines sub-group and a member of the QA sub-group.

Ms Karen Whitfield, Clinical Scientist, Bristol Haematology and Oncology Centre Karen Whitfield is a state registered Clinical Scientist working in the Radiotherapy Physics Unit at Bristol Haematology and Oncology Centre. Karen studied at Imperial College before entering the NHS training scheme at Kings College London, specialising in radiotherapy, ultrasound and nuclear medicine and where she also completed her MSc. She has worked in radiotherapy in Bristol for the past 7 years, with roles across a range of services but with a focus in dosimetry and IGRT. Mr Tom Williams, Trainee Medical Physicist, The Clatterbridge Cancer Centre After graduating from Durham University in 2010 with a MPhys (Hons) in Physics, Tom Williams undertook two months of voluntary work experience at The Clatterbridge Cancer Centre (CCC). Following this, a paid research position became available, and he spent eight months investigating the use of IMRT and VMAT for lung treatments. This culminated in the clinical implementation of VMAT for apical lung tumours, using a class solution developed by Tom. He went on to secure a place on the STP Medical Physics training scheme run by the Merseyside Training Consortium in 2011, and is currently in his third year completing his radiotherapy specialism at CCC. During this, Tom became involved in commissioning VMAT for SABR lungs, developing a class solution for planning these with Pinnacle SmartArc. He is now planning SABR lung patients clinically as part of the CCC SABR team.

Abstracts (where supplied) The principles and clinical evidence for SABR in different sites Dr Kevin Franks Stereotactic Ablative Radiotherapy (SABR) or Stereotactic Body Radiotherapy (SBRT) was developed in the Karolinska Institute in Sweden in the early 1990s. Based upon the principles of cranial radio-surgery, Blomgren and Lax developed the steretoactic body frame and delivered a short course of high dose hypo-fractionated radiotherapy to lesions in the chest and abdomen. They showed this approach could be associated with high rates of local control with acceptable toxicity. This approach was then adopted in Japan, North American and Europe for primary lung cancers and metastases above and below the diaphragm. There have been numerous peer-reviewed publications on SABR for lung lesions (both primary and metastases), liver (primary heptocellular and metastases), spine and more recently prostate and lymph node metastases. Technological advances in radiotherapy planning (4DCT and PET/CT), radiotherapy planning (IMRT/VMAT) and radiotherapy delivery (CBCT/Fiducial Tracking) have made this possible. In the UK the UK SABR consortium was formed in 2007 to address the lack of SABR in the UK. Although initially focusing on lung, the group has expanded to include other anatomical sites including prostate and liver. A lung cancer protocol was agreed in 2009 and now >1000 patients in >20 centres have been treated with SABR. Research is key to the development of SABR and although there is substantial evidence for SABR in phase I/II and institutional series there is a lack of randomised control evidence. Therefore, planned future UK SABR trials are a RCTs of SABR versus surgery for borderline operable stage I non-small cell lung cancer patients, SARON investigating the role of SABR in treating NSCLC patients with oligometases at presentation and CORE investigating SABR for the treatment of oligometases in lung, breast and prostate cancer after initial diagnosis and diagnosis and treatment. The comissioning process of SABR Dr Gareth Webster In recent years the clinical implementation of SABR has become increasingly widespread due to growing confidence in its clinical efficacy. Particularly fast uptake has been seen in the UK, from the first treatments beginning in 2009 to over 20 UK centres delivering SABR today. However, the delivery of these ablative radiation doses over 3-8 fractions represents one of the most safety-critical techniques in modern radiotherapy. The fact that the optimal clinical and technical approaches remain uncertain makes it crucial that SABR be implemented in a controlled and rigorously documented way. Making reference to the UK SABR Consortium guidelines, this talk will use the recent experience of implementation of lung SABR at UHB to illustrate several important requirements for safe implementation. This includes the need for:

• • • •

multi-disciplinary team working in anticipating and minimising treatment-related problems the local SABR programme to build on pre-existing experience in 4DCT expert knowledge to be acquired for all relevant equipment and processes prior to the start of the SABR programme and on-line image-guidance techniques regular audit of practice

It is hoped that, while not intending to be a comprehensive guide to SABR implementation, the talk will highlight key areas for consideration and will outline an approach that helps ensure safe and efficient treatment. Physics and quality assurance Mr Neil Richmond Quality assurance forms an integral part of all radiotherapy department treatment processes. The ultimate aim is to ensure the accuracy of dose delivery to the patient. Dosimetric and mechanical testing are seen as the preserve of clinical scientists but quality control of these alone does not guarantee that the prescribed treatment is administered in accordance with clinical intent. It is important that the broader aspects of treatment quality are subject to ongoing assessment on a per patient basis. Data collected as part of this quality assurance process should be scrutinised and used as a driver for process improvement and streamlining of the delivery pathway. Proffered Paper 1: Results of Patient specific Plan QA of NSCLC SABR with QUASAR anthropomorphic body phantom and MAPCHECK2 diode array Ms Vanya Staykova Materials and Methods: Two methods of Plan QA for NSCLC SABR have been implemented at NGH. The first method is absolute point dose measurement using a QUASAR body phantom with polystyrene foam inserts representing lungs and PTW31010 ionization chamber positioned in the middle of the insert using PMMA holder. The Verification plan, calculated with VARIAN Eclipse AAA, is a composite plan with gantry angles as for the plan and couch taken into account as additional structure. The second method uses a verification plan on MAPCHECK2 diode array and solid water and gamma analysis 2%, 2mm and 1%, 1mm in absolute mode to measure individual fields. Six 7-field-non-IMRT 6MV plans have been verified with both methods. Fields sizes (Clarkson equivalent square) vary between 3.7cm2-5.9cm2. Results: The average of all fields measured/calculated dose difference for the QUASAR phantom method is -1.7% (min 0.1%, max -3.0%) for individual fields, uncorrected for daily output (Figure 1). Total dose difference is between -1.3% and -2.6%. The average dose difference, corrected for daily output, is -2.4% (min -0.7%, max -4.6%) and total dose difference is between -1.4% and -4.1%. Five verification plans have been calculated with both 2mm and 1mm grid. The average difference has increased from -1.7% to -2.0% for output corrected doses with 1mm calculation grid.

Figure 1. The gamma pass rates with MAPCHECK2 are in the range of 96.3%-100.0% for 2%, 2mm gamma and 62.1%-93.7% for 1%, 1mm gamma. Conclusions: The first results of NGH SABR Plan QA showed very good agreement between calculated and measured point doses using QUASAR phantom, with systematically negative difference. The results confirmed the known issue for AAA that the dose in water after lung is overestimated for 6MV beams and fields ≥5x5cm. MAPCHECK2 results confirmed the spatial and dosimetric accuracy of AAA calculated fields with gamma pass 2%, 2mm gamma analysis. Manufacturer’s viewpoint Mr David James Clinical advances in the implementation of targeted, high-dose ablative radiotherapy have been aided by new technical capabilities that today provide unprecedented levels of accuracy and efficiency in treatment delivery. Precise beam collimation with the HD120 and 2½mm leaf thickness has been available since 2007 providing exceptional dose conformity for small, irregular shaped treatment volumes. In combination with RapidArc® planning, this has given clinicians new opportunities to sculpt the radiation delivery around critical structures yet maintain the required prescription dose. In this environment, precision imaging and patient alignment - also in 6 degrees of freedom - now become essential for each and every treatment fraction to ensure the pre-defined complex treatment fields may be delivered accurately.

For extracranial indications, motion management also becomes a critical factor to examine. Higher doses can be delivered faster using High Intensity beams where outputs of up to 2.400MU per minute permit shorter treatment times. New intra-fraction imaging techniques provide more frequent verification of the consistency of set-up and real-time tracking with Calypso electro- magnetic markers offers instantaneous feedback of any prostate or lung tumour shift. Varian’s technologies are seamlessly integrated to provide confidence in patient set-up, speed and accuracy in beam delivery as well as the ability for intra-fraction motion tracking. The combination of these capabilities allows SABR to become an option in a range of clinical scenarios without having to compromise on the tight time schedules per patient that represent the reality of the daily routine for a busy department. Manufacturer’s viewpoint Mr Barry Bonner The CyberKnife Robotic Radiosurgery System is the premier SABR device for full-body robotic Radiosurgery. It is designed to treat tumours with sub-millimetre accuracy using state of the art robotics and real time image guidance. For prostate, lung, liver and many other cancers it is a non-invasive alternative to surgery. There are also significant benefits for patients receiving conventional radiotherapy, often patients have to travel to hospital for 30 to 40 treatments. CyberKnife® can deliver a more accurate treatment with fewer side effects in less time, with typically 3 to 5 visits to hospital. The latest model of CyberKnife® is the M6™ Series which incorporates the first Multi Leaf Collimator (MLC) in combination with a Robotic Manipulator. The new InCise™ MLC is the only clinical solution to combine the benefits of MLC beam shaping with continual image guidance and non-isocentric, non-coplanar treatment delivery. This combination enables a precisely sculpted dose to spare healthy tissue whilst maintaining sub-millimetre accuracy – even for targets that move during respiration. The CyberKnife® is the next generation in Radiotherapy equipment. Manufacturer’s viewpoint Mr Amiya Roy Staying with today’s theme of Stereotactic Ablative Body Radiotherapy (SABR) I will discuss how Elekta’s Linear Accelerator Platform, VersaHD, is well positioned to provide technology with key elements such as State of the Art KV Imaging, safe verifiable treatment delivery, High Dose Rate beams and speed of treatment delivery.

4D-CT scanning and the SABR planning process Dr Simon Meara The aim of this presentation is to give a general introduction to 4D-CT scanning, and its use for SABR planning. Firstly, the concepts underpinning 4D-CT data acquisition and reconstruction are introduced. The construction of the average intensity projection (AIP) and maximum intensity projection (MIP) image data sets is then explained, along with the use of those images for radiotherapy treatment planning. Some of the technical considerations for 4D-CT scanning are discussed, and the concept of â&#x20AC;&#x153;back-up gatingâ&#x20AC;? is introduced. The presentation then moves on to the SABR planning process, concentrating primarily on SABR lung planning. The pre-treatment procedure is described, with mention of immobilisation devices. Contouring is then covered, including details of the organs at risk that should be outlined. Some specific considerations when generating a SABR lung treatment plan are presented: the positioning of the isocentre and the normalisation point; beam arrangements, both with fixed fields and with arc therapy; dose fractionation and prescription; and finally plan assessment, considering dose constraints to organs at risk and requirements for dose conformity. This is with reference to the guidelines published by the SABR UK Consortium. Some brief details on SABR spine planning are also given. Proffered paper 2: A review of challenging SABR lung cases Ms Gail Distefano Background SABR was implemented at the Royal Surrey County Hospital (RSCH) in January 2012 and we have since successfully treated 30 patients. We have a well established protocol, however like all complex treatment techniques, some cases required careful consideration. Method and Results At RSCH, Lung SABR is planned in Eclipse with a RapidArc solution. Our standard procedure utilizes two partial arcs to minimise entry through the contralateral lung. Three challenging case studies, where a non-standard approach was required, will be discussed. The first case is a patient who presented with bilateral FDG avid T1aN0 lesions, one of which was confirmed to be an adenocarcinoma. A separate plan was produced for each PTV (5.1cm3 and 6.0cm3 respectively) with each plan arc rotation limited between 0-180 and 180-360 respectively. A plan sum showed a lung V20= 3.6%. The second case is a T1bN0 adenocarcinoma left upper lobe, with PTV abutting the brachial plexus. This was planned with two full arcs and two avoidance-sectors, avoiding entry through the contralateral lung and ipsilateral brachial plexus. The final plan (55Gy/5#), was accepted with compromise to PTV coverage (D99=80%) to keep the dose to the brachial plexus as low as practical (d1cc =28Gy). Finally, the third case was a right sided posterior lesion which was found to have grown by 26% by day 0. This was replanned, however despite best efforts the patient was unable to cope with treatment and was offered palliative radiotherapy. Conclusion Challenging cases have been treated safely after careful consideration of alternative options and organ at risk tolerances.

Proffered paper 3: Evaluation of cyberknife prostate plans developed with 2 different template path techniques Mr Prasanasarathy Nariyangadu Aim: To compare prostate plans developed using two template path techniques available in the CyberKnife treatment planning system, Multiplan. Methods and Materials: For the purpose of this study, we developed two plans each for five prostate cases using the prostate path and the prostate intempo path respectively. The plans were optimized using the Ray Tracing algorithm and the cumulative dose volume histograms were used to compare the plans. The parameters evaluated were Conformality Index (CI), Planning Target Volume (PTV) coverage, volume of the rectum (VR,36Gy) and bladder (VB,37Gy) receiving 36Gy and 37Gy respectively and volume of the body encompassed by the 50% (VE,50%) and 30% (VE,30%) isodoses respectively. The statistical significance of the results were evaluated using the Paired students t test. Results: For all the five cases analysed the results were comparable. The average results are shown in the order of intempo vs. non-intempo respectively. CI (1.18±0.05 vs. 1.18±0.05), PTV coverage (96.80%±0.83 vs. 96.9%±0.86), VR,36Gy (1.69cc±1.04 vs. 1.38cc±0.72, P=0.14), VB,37Gy (6.02cc±2.93 vs. 5.60cc±3.28, P=0.33), VE,50% (316.68cc±28.74 vs. 328.84±24.53, P=0.01), VE,30% (855.82cc±259.23 vs. 859.14cc±222.54, P=0.86). The VR,36Gy and VB,37Gy are slightly larger in intempo path, although both were within the allowed dose tolerance limits. Conclusion: Overall, both categories of plans yielded similar results therefore either path is suitable for prostate planning. However, the intempo path may be a better path in terms of treatment delivery due to its adaptive imaging capability. Proffered paper 4: A smarter way of planning SABR lungs Mr Tom Williams The Clatterbridge Cancer Centre has recently treated its 100th SABR lung patient, using up to 9 fixed-fields. Planning these has been complex and time-consuming, involving extensive manual adjustment of MLCs. Building upon this experience, we sought a simpler solution to lessen the planning burden, improve conformality, and reduce treatment times. Here we present a planning study comparing the previous fixed-field technique to a new VMAT solution. A class solution was developed for planning SABR lung patients with SmartArc (Philips Pinnacle3 v9.6), using 2 partial-arcs, based on a range of previous cases covering the 3 fractionation regimes used clinically. An approximately central isocentre was required to remain within the CBCT safe-zone, resulting in increased field size and MLC leakage. Methods of minimising this were explored. Five patients were then dual-planned with fixed-fields and the SmartArc class solution.

The SmartArc plans greatly improved conformity (mean VPD/VPTV 0.98 vs 1.10, ideal=0.95) and dose fall-off outside the PTV. Where an OAR maximum dose was significant in the fixed-field plan, SmartArc was able to reduce this, while OAR already well below tolerance sometimes showed a slight increase in dose with VMAT (fixed-fields selectively avoided the OAR completely). VMAT also reduced the mean lung dose and total lung volume receiving high doses. Changes in contralateral and total lung V5 were less consistent. In all cases the clinician chose the SmartArc plan for treatment. Moving from fixed-field to VMAT for SABR lung patients has improved overall plan quality and provided a more straightforward planning process. Proffered paper 5: Using lung optimized treatment and Monte Carlo plan evaluation for treating lung lesions with a cyberknife. Dr Melvyn Folkard Lung Optimised Treatment (LOT) is an add-on package for CyberKnife (CK) that allows fiducial free treatments for a wide range of lung lesions, including situations where the tumour is not visible in either or both of the two imagers. The Mount Vernon Cancer Centre is the first UK site to adopt LOT for CK lung treatments. Prior to using LOT, 50% of lung patients were treated using fiducial tracking. Since using LOT, this has reduced to just 10%. However, if sub optimal imaging is used, the ITV and PTV margins should properly account for the inability to track some, or all of the target motion. Inverse-planning using ray tracing (RT) underpins the CK planning system. Tools for optimising and/or evaluating plans using Monte Carlo (MC) are also available, although no clear consensus exists on the best way of utilizing MC in CK treatments. Nevertheless, it is desirable to use MC for lung treatments as it is known that RT can overestimate target dose when low density tissue is involved. We have completed a study of ten lung patients initially planned using RT and show that for the same MU, the prescription dose is (on average) 5% lower after re-evaluating in MC, while PTV coverage reduces by ~15%. Therefore it is necessary to re prescribe at a lower dose and to a lower isodose after MC evaluation. For example, 60Gy to a peripheral lesion formerly planned with RT (78-80% isodose) would now be prescribed to 48Gy using MC at an isodose around 70-75%. Verification and treatment delivery: SABR from the radiographerâ&#x20AC;&#x2122;s point of view Mrs Marianne Dabbs St Lukeâ&#x20AC;&#x2122;s Cancer Centre, Guildford, introduced Lung-SABR in January 2012. After 22 months experience, the treatment has become embedded into the daily treatment schedule, with appointments becoming shorter, and delivery more streamlined. The verification pathway adopted from the start has remained unchanged, as it has proved to be reliable and robust.

Method By using the treatment experiences to date, we have developed a robust training package for the radiographers to follow. This is used in conjunction with the e-learning for health SABR package, available to all NHS staff. A SABR lead radiographer was appointed to organise and co-ordinate the training programme, and provide ongoing support during the treatments. Results A small team of senior radiographers are currently SABR competent. We are actively in the process of developing our radiographer led SABR delivery service. Our aim is to lead the treatments from the second fraction for all patients. This will ease the clinicianâ&#x20AC;&#x2122;s time pressures, whose presence would only be required for verification and day 1 treatment. Conclusion and Discussion Even though the SABR competent radiographers are matching the soft tissue on the verification images, there is now an emphasis to up-skill the staff on their decision making skills when matching difficult images. Having a small team of radiographers ensures that the skill base is maintained to a high standard; however problems can arise with staff availability at times. Proffered paper 6: Online CBCT verification for SABR Mrs Nazima Haji Introduction: Since May 2012, UCLH has treated 23 patients with a diagnosis of stage 1 non-small-cell lung cancer patients using SABR. All patients are treated using volumetric arc therapy (VMAT) on a TrueBeamTM STx. A significant challenge for SABR is to accurately and precisely deliver highly conformal, hypofractionated radiation doses to a small target while minimising dose to normal tissues and organs at risk (1,2,3). Therefore, for the implementation of this technique within a department, it is vital that a rigorous treatment verification protocol is developed. Method: Over the past five years, UCLH has developed itsâ&#x20AC;&#x2122; general lung practice with the implementation of 4DCT scanning and weekly CBCT verification. In order to establish an online CBCT verification protocol suitable for the delivery of SABR, an audit was undertaken of existing data. Based on this, and evidence within the literature (4,5), a daily imaging protocol was designed whereby a shift is applied following an online tumour match. CBCT images are acquired and reviewed pre-, mid, and post-treatment. In order to assess the impact of this protocol on the delivery of SABR and the validity of this imaging procedure, an audit was undertaken to evaluate both inter- and intra-fractional match variations. Conclusion: This presentation will describe the process of implementation of the verification protocol adopted at UCLH and discuss results from the audit. REFERENCES: 1.

Benedict SH, Yenice KM, Followill D et al. Stereotactic Body Radiation Therapy: The Report of AAPM Task Group 101. Med. Phys. 2010 37(8):4078-4101.

Bissonnette J-P, Purdie TG, Higgins JA et al. Cone-beam computed tomo graphic image guidance for lung cancer radiation therapy. Int J Radiat Oncol Biol Phys. 2009 73(3):927-934.

SABR UK Consortium. Stereotactic Ablative Body Radiation Therapy (SABR): A Resource. Version 4 Jan 2013.

Dahale M, Pearson S, Purdie T et al. Practical Considerations Arising from the Implementation of Lung Stereotactic Body Radiation Therapy (SBRT) at a Comprehensive Cancer Centre. J Thorac Oncol. 2008;3:1332â&#x20AC;&#x201C;1341.

Wang Z, Wu QJ, Marks LB et al. Cone-beam CT localization of internal target volumes for stereotactic body radiotherapy of lung lesions. Int J Radiat Oncol Biol Phys. 2007 1;69(5):1618-24.

Proffered paper 7: Imaging dose during cyberknife treatments Miss Philippa Sturt Image Guided Radiotherapy (IGRT) is a standard practice in the UK, with all patients receiving a form of IGRT during the course of their radiotherapy treatment. This is typically in the form of kV or MV planar or volumetric imaging performed immediately before treatment to verify patient setup. The CyberKnife Robotic Radiosurgery System not only uses imaging for patient setup but also to monitor and track target motion during treatment delivery, using pairs of kV images that are taken up to every 15 seconds. An audit was undertaken to monitor the imaging doses received by patients having CyberKnife treatment. Treatment records were examined retrospectively for 46 CyberKnife patients treated at Mount Vernon Cancer Centre between April and August 2013. The number of images taken during treatment and the exposure parameters used were combined with data measured by the Radiation Protection team to produce an estimated dose to the patient from imaging. The results were compared against values quoted in a white paper released by Accuray. The mean effective doses for brain, lung and prostate treatments were found to be of the same order of magnitude as those quoted by Accuray, although the number of images taken per treatment was generally higher. The audit highlighted other issues regarding the exposure parameters used for the radiation protection measurements, the size of the area exposed during imaging and the method used for estimation of imaging dose.

Proffered paper 8: Liver stereotactic body radiation therapy (SBRT) for metastatic liver disease: initial UK experience Dr Katharine Aitken Background Liver Stereotactic Body Radiotherapy (SBRT) is a novel local treatment modality for patients with metastatic liver disease (MLD). The aim of this retrospective review was to analyse the toxicity and outcome data of patients receiving liver SBRT for MLD at two UK centres. Methods Eligible patients had unresectable or medically inoperable MLD, Childs score A and performance status ≤2. Treatment was delivered with a linear accelerator (LA) using adaptive radiotherapy management or CyberKnife (CK). Dose was individualised according to the risk of radiation induced liver disease. Results From 12/2006 to 08/2013, 55 patients (65 lesions) received SBRT. We report 48 patients (primary cancer: colorectal 39, breast 5, sarcoma 3, anal 1). Median age 68 (range 41-85). Median gross tumour volume (GTV) 50.7 cc (range 2-614). Dose delivered 30-60 Gy in 3-10 fractions. Median Biologically Effective Dose (BED10) 56 (range 37.8-135). 1 patient had G3 toxicity (asymptomatic prolonged APTT). No higher grade toxicity observed. Median follow up 12.1 months (range 1.9-70.6). Median overall survival (OS) 19.3 months. 1 and 2 yr OS 69% , 42%. Median time to local failure (LF) 21.4 months. 1 and 2 year local control (LC) rates 71% , 44%. At last follow up 35/48 patient had distant progression (DP). BED ≥ 75 was associated with significantly improved local control rates compared to BED < 75 (p=0.006, HR for local failure (LF) 0.19, 1yr LC 94% vs 53%). Conclusion Liver SBRT is a novel local treatment modality for patients with MLD, associated with minimal toxicity. Early outcome data suggests local control rates are promising, particularly when BED ≥ 75. Proffered paper 9: Experiences of the UK SABR Consortium mentoring programme Ms Karen Whitfield Bristol Haematology and Oncology Centre is one of 3 UK radiotherapy centres to benefit from the pilot of a mentoring system set up by the UK SABR consortium to support departments wishing to implement a clinical SABR programme. We have been receiving support and expert guidance on all components of the patient pathway and independent verification from St James Institute of Oncology, Leeds. The mentoring process is summarised below: • Questionnaire • Scoping visit to recipient centre by mentors • Visit to supporting centre by recipient SABR team • Remote support from mentors to assist with setting up local protocols • Mentor physicist visit to recipient centre to support QA and planning of 1st clinical patient

â&#x20AC;˘ â&#x20AC;˘ â&#x20AC;˘

Mentor radiographer present for 1st treatment Remote support for subsequent patients for a further 3 months Dosimetry audit with a lung phantom

The snag was the short timescale, and the timing of the scheme which coincided with a host of other commissioning commitments. This meant delaying the introduction of VMAT and bringing in the technique before a new linac had been commissioned. The excellent support from Leeds, who have shared information and given honest and impartial advice, has made this all possible in a much shorter time than without the scheme. We are currently waiting for a suitable patient, a little behind the planned implementation date of October 2013. Overall we have found the scheme very positive and it should allow other centres to introduce this technique quickly and efficiently. Proffered paper 10: Paperlite SABR Ms Suzanne Jordan The current target is for the NHS to be paper free by 2018. This provides a challenge for radiotherapy, and specifically for SABR, as large amounts of data has to be generated, checked and then used to accurately and efficiently treat patients. At the Nottingham Radiotherapy Centre (NRC) steps towards becoming paperless have been taken by developing a paperlite system of work. This was achieved by adapting and adding to the current equipment, hardware and software so that the necessary data generated for each patient can reach all the areas required. An additional benefit of this system is the reduction of some common radiotherapy errors. Firstly, the need for manual data entry and recording has been reduced or eliminated therefore reducing the risk of transcription errors. Secondly there is a reduced likelihood of registering the wrong imaging data to the wrong patient data as both these systems now communicate with each other. The SABR technique generates more imaging data than other techniques as three or more scans may be taken during one treatment session. The Nottingham system is set up to automatically send the results to the couch top and record them in Mosaiq. This reduces the time spent manually undertaking these tasks and hence the length of the treatment time required for this group of patients. The paperlite system for delivering SABR at NRC is an effective and efficient one and works towards the 2018 goal of being paper free.

Our platinum sponsors

GE Healthcare GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality and more affordable healthcare around the world. GE (NYSE: GE) works on things that matter - great people and technologies taking on tough challenges. From medical imaging, software & IT, patient monitoring and diagnostics to drug discovery, biopharmaceutical manufacturing technologies and performance improvement solutions, GE Healthcare helps medical professionals deliver great healthcare to their patients.

Philips Healthcare Philips is a diversified health and well-being company and a world leader in healthcare, lifestyle and lighting. Our vision is to make the world healthier and more sustainable through meaningful innovation. We develop innovative healthcare solutions across the continuum of care, in partnership with clinicians and our customers to improve patient outcomes, provide better value, and expand access to care. As part of this mission we are committed to fuelling a revolution in imaging solutions, designed to deliver greater collaboration and integration, increased patient focus, and improved economic value. We provide advanced imaging technologies you can count on to make confident and informed clinical decisions, while providing more efficient, more personalised care for patients.

Siemens Healthcare The Siemens Healthcare Sector is one of the worldâ&#x20AC;&#x2122;s largest suppliers to the healthcare industry and a trendsetter in medical imaging, laboratory diagnostics, medical information technology and hearing aids. Siemens offers its customers products and solutions for the entire range of patient care from a single source â&#x20AC;&#x201C; from prevention and early detection to diagnosis, and on to treatment and aftercare. By optimising clinical workflows for the most common diseases, Siemens also makes healthcare faster, better and more cost-effective. For further information please visit: http://www.siemens.co.uk/healthcare

Our gold sponsor

Elekta Elekta is a human care company pioneering significant innovations and clinical solutions for treating cancer and brain disorders. The company develops sophisticated, state-of-the-art tools and treatment planning systems for radiation therapy, radiosurgery and brachytherapy, as well as workflow enhancing software systems across the spectrum of cancer care. Stretching the boundaries of science and technology, providing intelligent and resource-efficient solutions that offer confidence to both healthcare providers and patients, Elekta aims to improve, prolong and even save patient lives. Today, Elekta solutions in oncology and neurosurgery are used in over 6,000 hospitals worldwide. Elekta employs around 3,400 employees globally. The corporate headquarters is located in Stockholm, Sweden, and the company is listed on the Nordic Exchange under the ticker EKTAb. Website: www.elekta.com. If you have any product enquiries, please contact our UK office: Telephone:: +44 (0)1293 654488. Email: UKSales@elekta.com

FORTHCOMING BIR EVENTS Wessex branch winter meeting 13 december 2013 southampton north branch meeting: contrast study day and essesntial physics for FRCR 23-24 january 2014 liverpool radiology errors 31 january 2014 london BIR Scottish Branch meeting: Recent advances in diagnostic imaging 14 february 2014 glasgow 3rd annual spect/ct symposium: current status and future directions of spect/ct imaging 24 february 2014 london Multi-parametric imaging of prostate cancer can it facilitate a paradigm shift in management? 28 february 2014 london biological optimisation in radiotherapy 13 march 2014 london Paediatric body MRI 1 April 2014 lONDON Management and radiology - a guide to current and future management issues in radiology 2 May 2014 london Radiotherapy: Meeting the current workforce challenges for patient care 19 May 2014 London East of England Branch MEETING: Oncology hot topics june 2014 CAMBRIDGE Molecular Radiotherapy 4 june oxford GO TO WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

NOTES ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

NOTES ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ _______________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ _______________________________________________________ _______________________________________________________

For information and updates about BIR activities please visit our website: www.bir.org.uk or follow us on Twitter: @BIR_News