Clinical Implementation of Auto-Planning

Transcription

1 Clinical Implementation of Auto-Planning Ping Xia, Ph.D. Professor of Molecular Medicine Cleveland Clinic, Cleveland

2 Disclosures Philips: Research Grant Siemens: Research Grant

3 Why Auto-Planning? IMRT planning requires constant real time tuning of the planning objectives and extra contours Chinese Cooking method Highly dependent on how and when these tuning planning objectives and contours are added in optimizer - cooking process. It depends anatomical relationship among the OARs and PTVs - cooking ingredients.

4 What Is Auto-Planning (AP) AP is a new IMRT planning module in Pinnacle system, released in version Users can create their own cancer specific, machine specific, or IMRT delivery method specific AP technique to speed up IMRT planning recipe method Users can also use AP to perform IMRT optimization while setting other planning parameters such as beam angles, delivery method (step and shoot vs. VMAT) spontaneous method

5 I was Skeptical Auto-Planning could only work for simple cases Ideal candidates include sites with small variations in tumor shape and location - prostate cancer, possibly nasopharynx cancer. Challenging sites include head and neck cancer with variations in tumor shapes and locations.

6 Example 1 Oral Cavity Case Rx dose: 64 Gy, 60 Gy, and 54 Gy. Nine beams used in the clinical plan, Nine beam used in the auto-plan Step and Shoot (SS) plan 2 arcs used in auto-vmat plan

7 Clinical Plan Auto-Plan SS Auto-Plan VMAT 68.0, 64.0, 60.0, 54.0, 45.0, 35.0

8 Clinical Plan Auto-SS PTV-6400 Auto-VMAT Larynx PTV-5400 PTV-6000 Spinal Cord

9 Clinical Plan Auto-SS Auto-VMAT Oral Cavity-PTV

10 Example 2 Larynx Cancer Rx: 70 Gy and 56 Gy Clinical Plan: Nine beam angles Auto Plan: Nine beam Angles step and shoot (SS) Auto Plan: 2 arc VMAT

11 Clinical Plan Auto-Plan SS Auto-Plan VMAT 77.0, 70.0, 56.0, 45.0, 35.0 Gy

12 Clinical Plan Auto-SS Auto-VMAT PTV_7000 Oral Cavity Lips PTV_5600

13 Prostate High risk Prostate Rx: 78 Gy to prostate-ptv, 66 Gy to SV Clinical Plan: 7 beam angles Auto-Plan: 2 arc VMAT

14 Clinical Plan Auto-VMAT 80.0, 78.0, 70.0, 66.0, 45.0, 25.0 Gy

15 Clinical Plan Auto-SS Auto-VMAT PTV_6600 PTV_7800 RECTUM BLADDER

16 Clinical Plan Auto-SS Auto-VMAT PENILE BULB FEMUR_L FEMUR_R

17 EXAMPLE 1 50 year old with glioblastoma of right temporal region s/p NTR

18 Clinical Plan Auto Plan 60 Gy, 58.8 Gy, 51.0 Gy, 42.0 Gy, 36 Gy

19 Clinical Plan PTV_6000 Auto-plan OPTIC_NRV_L PTV_5100 BRAINSTEM COCHLEA_R

20 How it works Mimics the planners thought process Utilizes the planners tricks, such as creation of surrounding structures, tuning contours automatically Automatically runs multiple loops while adjusting planning objectives similar to what planners manually do

21 No More Negotiation With Optimizer IMRT planning was a process of negotiating with the optimizer. Adding tuning structures, cold spots, and hot spots. Auto-Planning allows us to simply state the dosimetric planning goals Auto-Planning automatically creates planning objectives and tuning structures that are required.

22 A Complex HN case 40 structures (include two tumor volumes) were contoured. 28 dose evaluation goals were input into auto-planning. 26 additional tuning structures were automatically created. 74 optimization objectives were automatically set for optimization.

23

24 AP for SBRT Plans

25 Advance Tool Setting

26 AP Spine SBRT 16 Gy,12 Gy,10 Gy

27 Input Planning Goals

28 Automatic Created Planning Objectives

29 Lung SBRT Re-planned 20 SBRT lung cases, 10 for peripheral tumors and 10 for central tumors. Ask physicians to rank quality of AP vs. Clinical plans. 15% AP plans are better, 80% AP plans are comparable, and 5% AP plans are worse than clinically approved plans.

30 Manual Plan AP Plan Gy

31 Central Lung SBRT AP Manual PTV Non-adjacent Trachea Non-adjacent Esophagus

32 Do We Know What We Want to Achieve in IMRT Planning?

33 CCF Cancer Specific Treatment Planning Guidelines and Dose Constraints 23 forms Or Found in in RTOG/NRG Protocols

34 CCF Pinnacle Plan Evaluation

35 Quantitative Plan Evaluation - Score Cards

36 How Are Total MUs Affected

37 AP for Special Cases

38 AP for Multiple Brain Mets A patient with multiple brain mets (6 mets) Using a single iso-center and five noncoplanar arcs. Three RXs concurrently: 30 Gy, 27.5 Gy, and 25 Gy in five fraction.

39 45 Gy 30 Gy 27.5 Gy 25 Gy 15 Gy

40 Apply AP to An Unusual Case 65.0 Gy 60.0 Gy 54.0 Gy 50.0 Gy 45.0 Gy 36.0 Gy 30.0 Gy Use two iso-centers and VMAT beams to produce the feathering regions. With AP, dosimetrists can produced this complicated plan with two runs of AP optimizations.

41 Magic Button: Cure without Complications Auto-Planning is a promising tool. Auto-Planning will improve plan quality and reduce planning time. Leverages dosimetrists human power, relying on the computer for grunt work. Auto-Planning will demand more computational power, not human power.

42 Acknowledgment Eric Murray, CMD, Diana Mattson, CMD. Lisa Zickefoose, CMD. Nicky, Vassil, CMD Matt Kolar. M.S. Zhilei Liu Shen, Ph.D. TingLiang Zhuang, Ph.D. Gauray Marwaha, M.D. John Suh, M.D. Erin Murphy, M.D. Sam Chao, M.D.

43 1 Pinnacle³ Auto-Planning

44 2 Introducing Pinnacle³ Auto-Planning Accelerating IMRT & VMAT planning

45 Today s Challenges in IMRT Planning Often a labor-intensive process generating inconsistent results There are many steps to IMRT treatment planning sometimes delaying start of treatment Process is tedious and repetitive requiring significant planner/physician interaction Plan quality varies depending on the experience of the user* creating inconsistencies in treatment 3 *Variation in external beam treatment plan quality: An inter-institutional study of planners and planning systems, Nelms et al, 2012

46 Simplified workflow with Pinnacle³ Auto-Planning A 3-step process reducing time & effort to create a plan Select Treatment Technique Evaluate with Scorecard 4 Run Auto-Planning

47 Pinnacle³ Auto-Planning Accelerating IMRT & VMAT planning Reduces the total time required to create an IMRT or SmartArc plan Replaces exhaustive manual data entry to just a few clicks Enhances plan quality and consistency Simplifies and standardizes the plan approval process 5

48 6 Product Highlights

49 Treatment Technique Automates repetitive data-entry for efficiency and standardization User-created searchable library Share technique files with other institutions Only need to be created at setup Similar to commissioning Can be edited at any time Contains parameters entered manually Derived ROIs (e.g. PTV, exp. cord) Isocenter & Prescriptions Machine parameters Treatment type (IMRT/DMPO or SmartArc) Optimization goals Multiple treatment techniques can be created per disease type, physician etc. Easy to capture existing practice with Create Technique from current trial 7

50 Auto-Planning Engine Generates high quality patient specific plans reducing planning time The Auto-Planning Engine iteratively optimizes to push target coverage and OAR sparing to the limit in a balanced manner Adds control structures for body and dose fall off Potential to reduce the need for multiple plan reviews with physician/physicist It runs in the background leaving the user free for other tasks The user has the flexibility to make adjustments at the end 8

51 Optimization goals A more intuitive method to drive optimization The actual goals the physician expects or desires to meet Different from IMRT objectives which typically need to be set different than actual goals The auto-planning engine creates and tunes the IMRT optimization settings Strives to meet the optimization goals in a balanced manner If necessary, extra objectives are created to meet higher priority goals 9

52 Progressive optimization algorithm Drives target coverage and sparing to the limits Auto-Planning achieves these results by mimicking the experienced planner Initial goal Auto-Planning Input data from Treatment Techniques Optimize Volume (cm 3 ) Auto-Planning Initial goal Deliver uniform dose to target Fine-tune Multiple IMRT optimizations Add Target objectives Add OAR objectives Add hot/cold spot objectives Fine tune each objective Evaluate Improve OAR sparing Dose (Gy) Output clinically acceptable plan 10

53 Scorecard Simplifies and standardizes the plan approval process User-created library of Clinical Goals to assess plan quality Intuitive user-interface providing at-a-glance information Facilitates standardization for plan approvals 11

54 Use with any IMRT/VMAT treatments Adaptable to a wide variety of patient specific situations HN, prostate, SBRT lung, standard lung, pancreas, breast, brain, rectal, etc Variations in prescriptions/targets Variations in OARs Variations in target/oar overlap Optional manual step Superclav beams Wedges/blocks/bolus Unique prescription Unique OAR goals 12

55 13 Example Results

56 Goals based on absolute dose A good plan can be achieved with relatively few inputs Contours that will be generated Treatment Technique for Head & Neck IMRT 14 Pinnacle³ Auto-Planning, June

57 H&N IMRT plan generated by Auto-Planning Multiple PTVs supported Isodose lines conform closely to PTV 15 Pinnacle³ Auto-Planning, June 2014

58 Head & Neck IMRT Scorecard Dose for organs at risk even lower than what was required Significant sparing of Brainstem benefits of the Progressive Optimization Algorithm 16 Pinnacle³ Auto-Planning, June 2014

59 17 Roots and Publications

60 In the beginning Initial technology and inspiration MD Anderson London Health Science Centre Johns Hopkins University 18

61 Auto-Planning was tested with major centers Validated performance against clinical practice & other algorithms Virginia Commonwealth University, VA University of Wisconsin, Madison, WI Odense University Hospital, Denmark Radboud University Nijmegen Medical Center, Netherlands University of Minnesota, MN University of Texas Health Sciences Center San Antonio, TX Clinique de Genolier, Switzerland Sichon Severance Hospital, South Korea 19

62 Recent Publications Showed favorable results for reducing overall planning time Total planning time could be reduced from about 4 hours to less than 30 minutes 20

63 Results presented at ASTRO 2013 Showed favorable results for plan quality when compared to clinical practice Automatic plans were able to meet all clinical goals achieved by physicists planning Automatic IMRT Treatment Planning using Templates with Automated Optimization Tuning Methods - Schuster et al Joint publication between VCU & Philips Evaluated Auto-Planning vs clinical practice on 15 patients with locally advanced lung cancer Physicians chose algorithmic auto-plans 75% of the time Automatic Planning of Head and Neck Treatment Plans - a Way to Optimize the Plan Quality and Reduce Workload Hazell et al. Joint publication between Odense & Philips Retrospective planning study on 26 patients with Oropharyngeal carcinoma 21

64 Odense Study Results Reduced parotid and cord doses in most plans 22 Automatic Planning of Head and Neck Treatment Plans - a Way to Optimize the Plan Quality and Reduce Workload Hazell et al.

65 Upcoming Studies Clinical results to be revealed at upcoming meetings Nijmegen Hodgkin lymphoma (step and shoot) Prostate (VMAT) Breast (IMRT and conventional) SBRT Lung Conclusion: With the automated planning module it is possible to consistently create high quality clinical plans for different tumour sites independent of the user, similar to the original clinical plans that were used as a reference. Breast Ghent University Hospital Conclusion: The optimization time was significantly shorter for the APs than for the MPs. Two ROs preferred the AP over the MP for 10/10 patients, while the third RO preferred the AP over the MP for 6/10 patients. 23 Cleveland Clinic Conclusion: Dr. Xia will show results next

66 Auto-Planning at the Pinnacle³ Plan Challenge Better results than the median at a fraction of the time Auto-Planning (~ 30 mins) Traditional IMRT planning (~ 3-4 hours) plans submitted by Pinnacle³ users competing to win the plan challenge 24

67 Pinnacle³ Auto-Planning Accelerating IMRT & VMAT planning Reduces the total time required to create an IMRT or SmartArc plan Simplified 3-step process reduces time & effort to create a plan Replaces exhaustive manual data entry to just a few clicks Treatment Techniques created at setup are used repeatedly for each plan Enhances plan quality and consistency The Auto-Planning Engine generates high quality plans at the 1 st pass Simplifies and standardizes the plan approval process Scorecards reduce the need for multiple plan reviews 25

68 Pinnacle³ Auto-Planning Continuing the trend of smart automation to increase quality & efficiency Reduce contouring time Reduce time for planning & review Reduce assessment & re-planning time SPICE Auto-Planning Dynamic Planning 26

69 27