Biological optimisation of radiotherapy treatment planning by BIR Publishing

Biological optimisation of radiotherapy treatment planning Registered charity no: 215869

13 March 2014 Venue: Stewart House, London 4 CPD credits

BIR Annual Congress 2014: 22-23 October, London

Welcome and thank you for coming to the â&#x20AC;&#x2DC;Biological optimisation of radiotherapy treatment planningâ&#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 4 RCR category I CPD credits. CPD certificates will be distributed by email within two weeks of the meeting once 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/_biological We hope you find the day interesting and enjoyable. Professor Andrew Beavis and Dr Keith Langmack Meeting Organisers Radiotherapy Physics SIG, BIR

We are most grateful to

for supporting this conference

Programme

09:30 Registration and refreshments Chair: Professor Andrew Beavis, Head of Radiotherapy Physics, Hull and East Yorkshire Hospitals NHS Trust 10:00 Introduction 10:05 The clinical perspective of biological optimisation of radiotherapy treatment Professor Tim Maughan, Professor of Clinical Oncology, Gray Institute for Radiation Oncology and Biology, University of Oxford 10:45 Biological optimisation in treatment planning systems Mr Kjell Eriksson, Senior Research Engineer, RaySearch Laboratories 11:25 Refreshments 11:45

Using radiobiology to individualise dose and fractionation Professor Alan Nahum, Head of Physics Research, The Clatterbridge Cancer Centre NHS Foundation Trust and Visiting Professor, University of Liverpool

Proffered papers 12:25 Tumour control probability and normal tissue complication probability consequences of boosting dominant intra-prostatic lesions in the context of prostate stereotactic ablative radiotherapy Louise Murray, Cancer Research UK Clinical Research Fellow, University of Leeds/St Jamesâ&#x20AC;&#x2122;s Institute of Oncology 12:40 A population-based radiobiological approach to radiotherapy treatment optimisation Dhvanil Karia, PhD student, Physics Department, Clatterbridge Cancer Centre and University of Liverpool 12:55 Lunch Proffered papers 14:00 Optimising particle therapy by better knowledge of RBE Bleddyn Jones, Professor of Clinical Radiation Biology, University of Oxford

14:15 Potential impacts of intercellular signalling in radiotherapy optimisation Stephen McMahon, Research Fellow, Queenâ&#x20AC;&#x2122;s University, Belfast 14:30

Radiobiological determination of dose escalation and normal tissue toxicity in oesophageal cancer Samantha Warren, Radiotherapy Physics Researcher, Gray Insitute for Radiation Oncology and Biology

14:45 63 years of radiobiology for radiotherapy Professor Jack Fowler, Retired, London 15:25 Refreshments 15:45

Control and complications: predicting radiotherapy outcome and functionally - optimising treatment Dr Colin Baker, Clinical Physicist, The Clatterbridge Cancer Centre NHS Foundation Trust and Honorary Lecturer, The University of Liverpool

16:25 Discussion 16:45 Close of meeting

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

BIR Annual Congress 2014: 22-23 October, London

Speaker profiles (where supplied)

Mr Kjell Eriksson Senior Research Engineer, RaySearch Laboratories Kjell Eriksson trained in engineering physics before joining the newly founded company RaySearch Laboratories AB in 2001. As a part of the research group at RaySearch he is a specialist in optimisation algorithms and radiobiological models. He was a main contributor in the development of direct machine parameter optimisation (DMPO) in Pinnacle and the VMAT algorithm in both Pinnacle and Oncentra, as well as the radiobiological tools in Pinnacle and Eclipse. Since 2011 his focus has been on optimisation algorithms for automatic planning and the radiobiological tools in RayStation, the new treatment planning system from RaySearch.

Professor Tim Maughan Professor of Clinical Oncology, Gray Institute for Radiation Oncology and Biology, University of Oxford Tim Maughan studied medicine at Cambridge and UCH, London and undertook his research training at Cambridge under Professor Norman Bleehen at the MRC Clinical Oncology and Radiotherapeutics Unit. Thereafter he worked as an NHS consultant Clinical Oncologist in Cardiff, becoming Professor of Cancer Studies in 2007. During that time, he established the first clinical research network, the Wales Cancer Trials Network, and was subsequently involved in the development of the clinical research networks across the UK. Timâ&#x20AC;&#x2122;s research has focused on colorectal cancer, culminating in the FOCUS4 trial of molecular selection of treatment, which is now recruiting patients across the UK. From 2008-10, Tim was the founding chair of the NCRI Clinical and Translational Radiotherapy Research Working Group (CTRad), which has a broad remit to enhance radiotherapy research in the UK. Tim was appointed Professor of Clinical Oncology and Deputy Director of the MRC-CRUK Oxford Institute of Radiation Oncology, Department of Oncology at the University of Oxford in 2011. His role in Oxford is to lead the clinical research programme at the Oxford Institute, focusing on improving outcomes in the radical treatments of cancers of unmet need in oesophagus, pancreas, lung, bladder and rectum.

Professor Alan Nahum

Head of Physics Research, The Clatterbridge Cancer Centre NHS Foundation Trust and Visiting Professor, University of Liverpool Alan Nahum is head of Physics Research at Clatterbridge Cancer Centre (CCC) and Visiting Professor at Liverpool University Physics Department. His PhD was on Theoretical Radiation Dosimetry (Edinburgh University, 1975). After four years as a school science teacher he joined the Medical Radiation Physics department at Umeå university (Sweden) where he taught radiation physics and worked on ion-chamber correction factors and codes of practice for reference dose determination in external-beam radiotherapy, including a sabbatical at the National Research Council of Canada, Ottawa, in Dave Rogers’ Radiation Standards group. Between 1985 and 2002 he was a member of the Physics Research group at the Royal Marsden Hospital/Institute of Cancer Research, Sutton, working on conformal therapy, radiation dosimetry and ‘biological’ modelling (TCP, NTCP). Short spells at Fox-Chase Cancer Center (Philadelphia), Reggio Emilia (Italy) and Copenhagen followed. He moved to Clatterbridge in 2004. His current major interests are in using TCP and NTCP models to optimise radiotherapy treatment and in using Monte-Carlo simulation to improve our understanding of dosimeter response, especially in ‘small’ photon fields e.g. as used in SABR, Cyberknife and IMRT. In 2006 he started the Clatterbridge course ‘Radiobiology & radiobiological modelling in radiotherapy’, now in its ninth year. Handbook of radiotherapy physics – theory and practice, ed. Mayles, Nahum and Rosenwald, appeared in 2007. ____________________________________________________________________ Abstracts (where supplied) Biological optimisation in treatment planning systems

Mr Kjell Eriksson

In contrast to conventional treatment plan optimisation, where the optimisation problem is based on tolerance dose levels, biological optimisation problems are stated more directly in terms of clinical outcome. Hence, rather than specifying dose levels prior to the optimisation, the desired clinical outcome is defined and the dose distribution is instead the result following the biological optimisation. With biological models in treatment planning, the optimal dose distribution is different for different fractionation schedules, patient geometries, treatment modalities, etc. It is possible to create algorithms that optimise not only the dose distribution for a given fractionation schedule, but also new variables such as the number of fractions and time of delivery. Biological models are especially well suited to drive optimisation when the fractionation schedule has been modified and a plan with equivalent expected clinical outcome must be created. Biological models create opportunities, but there are also challenges.

One challenge is that clinical protocols usually state the clinical goals in terms of tolerance doses rather than with biological indices. Therefore, it is important to allow combined physical and biological optimisation functions so that biological objectives may improve the expected outcome, while the physical constraints make sure that the protocol is followed. Another challenge is model limitations and uncertainties. It is possible to introduce robust biological optimisation where the model uncertainties are accounted for. In this presentation, examples are given of how biological models are used for optimisation in some existing commercial treatment planning systems, and speculations on future developments are made.

Using radiobiology to individualise dose and fractionation Professor Alan Nahum Educational aims: To understand the role that radiobiology and, in particular, radiobiological models of tumour control probability (TCP) and normal-tissue complication probability (NTCP), can play in individualising prescription dose and fractionation scheme for patients undergoing external-beam radiotherapy. Abstract: Today’s radiotherapy is technologically sophisticated (3D inverse-planning systems; 3D ‘physical’ and ‘functional’ imaging; computer-controlled multileaf collimators; ever-increasing dose conformality improved by image-guidance). However, almost no active use is made of the vast store of radiobiological knowledge built up over the second half of the previous century. Thus clinical protocols specify a fixed tumour dose and fixed fraction size; this fails to exploit the potential to individualise the tumour dose, which is almost as great as the variation in individual patient anatomy. By using radiobiologically-based models of tumour control probability (TCP) and normal-tissue complication probability (NTCP), the tumour dose can be selected such that a pre-set NTCP is reached (‘isotoxicity’), including the exploration of different numbers of fractions. Current UK phase-I/II trials IDEAL and I-START for NSCLC deliver individualised ‘isotoxic’ prescription doses; SABR is an example of quasi-individualised hypofractionation. Furthermore, one of the principal objectives in inverse (IMRT) planning ought to be the maximisation of TCP whilst not exceeding X% NTCP. Examples will be given of plans with isotoxically customised prescription doses at both fixed and ‘optimised’ fraction number, and of radiobiologically-guided ‘inverse’ plans. The main impediment to the clinical implementation of such strategies is the almost total absence of radiobiology in today’s commercial treatment planning systems, with one, possibly two exceptions. Learning outcomes: To appreciate the potential of treatment-plan individualisation, and the resulting improvement in clinical outcomes, from the active use of models of TCP and NTCP in radiotherapy treatment planning.

63 years of radiobiology for radiotherapy Professor Jack Fowler I started working in September 1950 at the RVI in Newcastle as the Junior Physicist of Frank Farmer’s team of 5 physicists, 3 Radium Technicians, and 3 workshop staff. Although there was absolute priority for each day’s work on the patients, such as planning individual treatments for each patient, we were also aware that as scientists we were responsible for any research improvements that could increase the results of radiotherapy treatments, such as designing smaller ionisation chambers to measure doses more accurately, working on detailed treatment plans for rotation therapy, which we did with 250 KV X-ray machines, (similar to tomotherapy in principle in 1950 but without computers!) There were also many questions that we asked about the methods then in use. Why didn’t we treat at weekends? Didn’t tumours grow every day? Why were some treatments given in 4 weeks and others in 6 or 7 weeks? And always the basic rule of all medicine, not to do too much harm with high radiation doses. Cobalt-60 machines came in in 1960; Linear Accelerators came along from Metropolitan Vicker and Phillips in1951, 10 years before Varian produced any in the USA. Although Varian’s Klystrons helped us to win the Battle of the Atlantic in 1943 with better radar, which could see the small snorkel air-tubes that U-boats could use to remain submerged.

BIR Annual Congress 2014: 22-23 October, London

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FORTHCOMING EVENTS Paediatric body MRI course 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 and future workforce challenges for patient care in a changing context 19 May 2014 London Molecular radiotherapy dosimetry 4 June 2014 Oxford wESSEX BRANCH MEETING 13 jUNE 2014 wINCHESTER OPTIMISATION IN CT 18 JUNE EDINBURGH EAST OF ENGLAND BRANCH MEETING: ONCOLOGY HOT TOPIcS JUNE 2014 CAMBRIDGE irmer update 29 september 2014 london Diagnostic radiology for advanced head and neck cancer planning 2 October 2014 london Optimisation in interventional radiology 10 October 2014 birmingham Linking orthopaedics and radiology II - the plain film revisited: the upper limb 16 October 2014 london

BIR Annual Congress 2014: 22-23 October, London VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!

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