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2.Broadening the therapeutic band width - Cambridge 2016 v1.1 - handout + lecture.pdf 		1
Slide Number 1 		1
Broadening the therapeutic band width Neil Burnet 		2
Slide Number 3 		3
Introduction 		4
RT is potent and cost-effective 		5
Introduction 		6
Quality of RT affects outcome 		7
Quality of RT affects outcome 		8
Quality of RT affects outcome 		9
Quality of RT affects outcome 		10
Slide Number 11 		11
Slide Number 12 		12
Broadening RT band width 		13
Broadening RT band width 		14
Slide Number 15 		15
Increase the therapeutic ratio 		16
Increase the therapeutic ratio 		17
Increase the therapeutic ratio 		18
Increase the therapeutic ratio 		19
Increase the therapeutic ratio 		20
Increase the therapeutic ratio 		21
Normal tissue toxicities 		22
Pelvic Ewing’s sarcoma 		23
Normal tissue response 		24
Normal tissue response 		25
Normal tissue response 		26
Normal tissue response 		27
Normal tissue response 		28
Normal tissue response 		29
Slide Number 30 		30
Image guidance 		31
Broadening the band width 		32
Broadening the band width 		33
Broadening the band width 		34
Broadening the band width 		35
Broadening the band width 		36
Broadening the band width 		37
Treatment volumes compared 		38
Use the best equipment you can! 		39
Ca prostate 		40
Ca nasopharynx 		41
Ca breast 		42
Slide Number 43 		43
IMRT for chordoma 		44
IMRT for chordoma 		45
Bandwidth 		46
Conclusions 		47
Slide Number 48 		48
3.DoseAlgorithms 		49
Slide Number 1 		49
Slide Number 2 		50
Acknowledgements 		51
Computer-Aided Treatment Planning 		52
Dose Calculation Problem 		53
Complexity of dose calculation 		54
Expectations 		55
Dose Calculation Methods 		56
Evolution of Photon Beam Dose Algorithms 		57
X-Rays: Energy Deposition in a Nutshell 		58
Dose Spread Kernel 		59
Method: Convolution/Superposition 		60
Convolution - Point Kernel 		61
Pencil Kernel Integration 		62
Pencil beam kernel 		63
Pencil beam kernel 		64
Breast Tangent Example 		65
Total Energy Released per MAss (TERMA) 		66
Physics considerations 		67
Influence of Head Scatter 		68
CT Data to Tissue Properties 		69
Images Support Dose Calculations 		70
Density Scaling Approximation 		71
Calculated Data 		72
Electronic Disequilibrium 		73
Summary model based & MC approaches 		74
Advanced Kernel Methods 		75
RPC/RTOG phantom for SBRT 		76
A Simple Algorithm Check 		77
A Simple Algorithm Check: MU’s 		78
Energy Absorbed by an Inhomogeneity 		79
Energy Absorbed by an Inhomogeneity 		80
Clinical impact of dose calculation 		81
Summary – Evolution, not Revolution 		82
4.ICRU planning and prescribing - Cambridge 2016 - v1.1 handout + lecture 		83
Slide Number 1 		83
ICRU guidance on planning and prescribing Neil Burnet 		84
Summary 		85
The history of radiotherapy 		86
ICRU guidance 		87
ICRU guidance 		88
Prescribing 		89
Prescribing 		90
Prescribing 		91
Prescribing 		92
Prescribing 		93
Prescribing 		94
Prescribing 		95
Prescribing 		96
Prescribing 		97
Prescribing 		98
Prescribing 		99
Prescribing 		100
Prescribing 		101
Prescribing 		102
Prescribing 		103
Lung doses 		104
Prescribing 		105
Prescribing 		106
ICRU guidance 		107
Slide Number 26 		108
Target volumes 		109
Target volumes 		110
Summary 		111
Target volumes - PTV 		112
Target volumes - PTV 		113
Slide Number 32 		114
Other volumes - TD 		115
Other volumes - RVR 		116
Target volumes – OARs 		117
Target volumes – OARs 		118
Target volumes – OARs 		119
Target volumes – OARs 		120
Target volumes – OARs 		121
Target volumes – OARs + PRVs 		122
Target volumes – OARs + PRVs 		123
Target volumes – OARs + PRVs 		124
Target volumes – PRV 		125
Target volumes – PRV or optimising structure? 		126
Hypothalamus DVHs 		127
Hypothalamus DVHs 		128
Hypothalamus DVHs 		129
Planning dose limits 		130
Planning limits 		131
Planning constraints 		132
Planning constraints 		133
Planning constraints 		134
Prioritising 		135
Slide Number 54 		136
Objectives and Priorities 		137
GBM - IMRT plan DVHs 		138
Constraints and Priorities 		139
Target volumes – overlaps 		140
Target volumes – overlaps 		141
Target volumes – overlaps 		142
Target volumes – overlaps 		143
Target volumes – overlaps 		144
Target volumes – overlaps 		145
Target volumes – overlaps 		146
Take home messages 		147
Slide Number 66 		148
Slide Number 67 		149
ICRU guidance 		150
Homogeneity Index 		151
Conformity Index 		152
Equivalent Uniform Dose - EUD 		153
Equivalent Uniform Dose - EUD 		154
Equivalent Uniform Dose - EUD 		155
TCP, NTCP, PUC 		156
Slide Number 75 		157
 Tissue architecture 		158
Target volumes – PRV 		159
Target volumes – PRV 		160
Target volumes – PRV 		161
5.nonIMRT 		162
Slide Number 1 		162
Slide Number 2 		163
Slide Number 3 		164
Slide Number 4 		165
Slide Number 5 		166
Slide Number 6 		167
Slide Number 7 		168
Slide Number 8 		169
Slide Number 9 		170
Slide Number 10 		171
Slide Number 11 		172
Slide Number 12 		173
Slide Number 13 		174
Slide Number 14 		175
Slide Number 15 		176
Slide Number 16 		177
Slide Number 17 		178
Slide Number 18 		179
Slide Number 19 		180
Slide Number 20 		181
Slide Number 21 		182
Slide Number 22 		183
Slide Number 23 		184
Slide Number 24 		185
Slide Number 25 		186
Slide Number 26 		187
Slide Number 27 		188
Slide Number 28 		189
Slide Number 29 		190
Slide Number 30 		191
Slide Number 31 		192
Slide Number 32 		193
Slide Number 33 		194
Slide Number 34 		195
Slide Number 35 		196
Slide Number 36 		197
Slide Number 37 		198
Slide Number 38 		199
Slide Number 39 		200
Slide Number 40 		201
Slide Number 41 		202
Slide Number 42 		203
Slide Number 43 		204
Slide Number 44 		205
Slide Number 45 		206
Slide Number 46 		207
Slide Number 47 		208
Slide Number 48 		209
6.Lung relation between 3D dose distributions and clinical toxicities new update on site 		210
Slide Number 1 		210
Relationships between 3D dose distributions and clinical toxicities - Chest 		211
SBRT: success story 		212
SBRT: improving outcomes stage I LC 		213
„Standards“ for dose/prescription to PTV? 		214
SBRT: wide use, high heterogeneity 		215
SBRT: „magic BED10“ of 100 Gy? 		216
Slide Number 8 		217
Elekta group: Doses vs. outcome 		218
SPACE - A randomized study of SBRT vs conventional fractionated radiotherapy in medically inoperable stage I NSCLCJ. Nyman et al. world lung 2015 		219
Central tumors: outcome from expert treatment 		220
Central tumors 		221
Toxicity! 		222
Pat. S.D. *1943, SCC 		223
Another fatal necrosis after central SBRT… 		224
Slide Number 16 		225
Slide Number 17 		226
Slide Number 18 		227
Slide Number 19 		228
Slide Number 20 		229
Slide Number 21 		230
Slide Number 22 		231
Slide Number 23 		232
Slide Number 24 		233
Slide Number 25 		234
Slide Number 26 		235
Slide Number 27 		236
Course post SBRT 		237
Slide Number 29 		238
Esophageal toxicity 		239
Slide Number 31 		240
Slide Number 32 		241
Slide Number 33 		242
Slide Number 34 		243
Slide Number 35 		244
Slide Number 36 		245
Slide Number 37 		246
There is more than dose and fractionation… 		247
9.Planning Aspects Breast Cancer_DvdBongard 		248
Slide Number 1 		248
Slide Number 2 		249
Planning aspects in breast RT 		250
Slide Number 4 		251
Slide Number 5 		252
Slide Number 6 		253
Breast-conserving surgery +/- whole breast RT 		254
RT after mastectomy and axillary lymph node dissection 		255
Slide Number 9 		256
Regional lymph node irradiation – delineation on planning CT 		257
Slide Number 11 		258
Therapeutic window: principle of radiotherapy 		259
Radiotherapy-induced toxicityLocal radiotherapy (Breast/Chest wall) 		260
Radiotherapy-induced toxicityRegional radiotherapy 		261
Acute toxicity skin - Radiation dermatitis 		262
Late skin / breast toxicity 		263
Lung - Radiation pneumonitis (subacute toxicity) 		264
Left-side breast cancer and RTThe heart 		265
Radiation-induced heart disease 		266
Radiation-induced heart diseaseRegional radiotherapy 		267
Cardiac toxicity and mortality due to RT 		268
Arm oedema -After axillary surgery and/or regional radiotherapy 		269
Regional radiotherapy instead of axillary surgery 		270
Brachial plexus Regional radiotherapy boost 		271
Radiation-induced secondary cancer after breast radiotherapy 		272
Planning aspects in breast RT 		273
Hypofractionation – breast Radiotherapy 		274
Hypofractionation – whole breast irradiation 		275
Canadian study 		276
Toxicity – hypofractionated and conventional scheme 		277
Hypofractionation – Clinical practice 		278
Hypofractionation – FAST (FORWARD) 		279
Planning aspects in breast RT 		280
Partial breast RT - Rationale 		281
Accelerated partial breast RT - Advantages 		282
Accelerated Partial breast RT (APBI) - guidelines 		283
APBI – low-risk patients 		284
APBI - Methods 		285
APBI - Methods 		286
APBI - External Beam RT 		287
Whole vs. Partial breast irradiation – phase III studies 		288
Whole vs. Partial breast irradiation – phase III studies 		289
Extreme breast hypofractionation – preoperative single-dose PBI 		290
Preoperative single dose Radiotherapysupine position – UMC Utrecht 		291
MRI – complete response 		292
Planning aspects in breast RT 		293
Optimal cardiac sparing – Breath-hold technique 		294
Breath hold techniques 		295
UMC Utrecht – voluntary deep inspiration breath hold techniquelocal +/- regional lymph nodes 		296
Breath hold analysis 		297
Breath hold technique 		298
Compliance Breath hold technique 		299
Planning aspects in breast RT 		300
Forward IMRT / 3DCRT 		301
More advanced planning techniquesin breast cancer patients 		302
Comparison of 3D-CRT, IMRT, VMAT in locoregional RT (including internal mammary nodes) 		303
3D-CRT compared with VMAT 		304
Multibeam-IMRT compared with VMAT 		305
Comparison of 3D-CRT, IMRT, VMAT locoregional RT including IMN 		306
Other indications VMAT - Funnel chest Heartl 2014 		307
What about second cancer risk? 		308
Recommendations VMAT and m-IMRT 		309
Take home messages – innovations in RT breast cancer 		310
Thank you for your attention! 		311
Planning aspects in breast RT 		312
Boost on tumor bed: decreased local recurrence 		313
Boost on tumor bed – breast fibrosis 		314
Breast fibrosis – Increased risk of 		315
Simultaneously integrated boost (SIB)instead of sequential boost 		316
Sequential boost vs. SIB 		317
Simultaneously integrated boost (SIB) 		318
Preoperative external beam Radiotherapyprone position 		319
sp 		320
Slide Number 74 		321
Slide Number 75 		322
Treatment and Toxicity - Conclusions 		323
9a.Breast case_2016 		324
Slide Number 1 		324
Case 1: Breast 		325
Introduction case 1: Breast and regional lymph nodes (i.e. axillary, supraclavicular and internal mammary nodes) 		326
Mrs H, 54 years old 		327
Titles in Arial 		328
Titles in Arial 		329
Titles in Arial 		330
Titles in Arial 		331
BI-RADS: Breast Imaging-reporting and data system 		332
BI-RADS classification 		333
Mrs H, 54 years old 		334
Mrs H, 54 years old 		335
MRI - BI-RADS classification 		336
Slide Number 14 		337
Mrs H, 54 years old 		338
Slide Number 16 		339
Slide Number 17 		340
Mrs H, 54 years old 		341
Slide Number 19 		342
Slide Number 20 		343
Mrs H, 54 years old 		344
Mrs H - Treatment 		345
Mrs H - Treatment 		346
Locoregional RT – Organs at risk 		347
Breast planning – session objectives 		348
11.Practical aspects of IMRT planning 		349
Slide Number 1 		349
Optimalisation 3DCRT 		350
Optimalisatie IMRT 		351
Slide Number 4 		352
Slide Number 5 		353
Optimization 		354
20 tips and tricks for happy IMRT planning 		355
20 tips and tricks for happy IMRT planning 		356
20 tips and tricks for happy IMRT planning 		357
20 tips and tricks for happy IMRT planning 		358
20 tips and tricks for happy IMRT planning 		359
20 tips and tricks for happy IMRT planning 		360
20 tips and tricks for happy IMRT planning 		361
20 tips and tricks for happy IMRT planning 		362
20 tips and tricks for happy IMRT planning 		363
20 tips and tricks for happy IMRT planning 		364
Slide Number 17 		365
what happens to the dose in the posterior part of PTVwhen the patient is shifted 1 cm dorsally? 		366
Slide Number 19 		367
20 tips and tricks for happy IMRT planning 		368
20 tips and tricks for happy IMRT planning 		369
20 tips and tricks for happy IMRT planning 		370
20 tips and tricks for happy IMRT planning 		371
20 tips and tricks for happy IMRT planning 		372
20 tips and tricks for happy IMRT planning 		373
20 tips and tricks for happy IMRT planning 		374
20 tips and tricks for happy IMRT planning 		375
20 tips and tricks for happy IMRT planning 		376
20 tips and tricks for happy IMRT planning 		377
20 tips and tricks for happy IMRT planning 		378
20 tips and tricks for happy IMRT planning 		379
20 tips and tricks for happy IMRT planning 		380
20 tips and tricks for happy IMRT planning 		381
20 tips and tricks for happy IMRT planning 		382
20 tips and tricks for happy IMRT planning 		383
20 tips and tricks for happy IMRT planning 		384
Slide Number 37 		385
Conclusions 		386
12.practical aspects IMRT 		387
Slide Number 1 		387
Slide Number 2 		388
Slide Number 3 		389
Slide Number 4 		390
Slide Number 5 		391
Slide Number 6 		392
Slide Number 7 		393
Slide Number 8 		394
Slide Number 9 		395
Slide Number 10 		396
Slide Number 11 		397
Slide Number 12 		398
Slide Number 13 		399
Slide Number 14 		400
Slide Number 15 		401
Slide Number 16 		402
Slide Number 17 		403
Slide Number 18 		404
Slide Number 19 		405
Slide Number 20 		406
Slide Number 21 		407
Slide Number 22 		408
Slide Number 23 		409
Slide Number 24 		410
Slide Number 25 		411
Slide Number 26 		412
Slide Number 27 		413
Slide Number 28 		414
Slide Number 29 		415
Slide Number 30 		416
Slide Number 31 		417
Slide Number 32 		418
Slide Number 33 		419
Slide Number 34 		420
Slide Number 35 		421
Slide Number 36 		422
Slide Number 37 		423
13.Physical and biological optimisation 		424
Physical and biological optimisation 		424
Slide Number 2 		425
Slide Number 3 		426
Slide Number 4 		427
Slide Number 5 		428
Slide Number 6 		429
Optimization in the biology domain 		430
Slide Number 8 		431
Slide Number 9 		432
Slide Number 10 		433
Equivalent uniform dose 		434
Equivalent uniform dose 		435
Equivalent uniform dose 		436
Equivalent uniform dose 		437
Equivalent uniform dose 		438
Equivalent uniform dose 		439
Slide Number 17 		440
Slide Number 18 		441
Can we go beyond EUD? 		442
Can we go beyond EUD? 		443
Slide Number 21 		444
Slide Number 22 		445
Conclusions 		446
14.Particle therapy planning 		447
Slide Number 1 		447
Slide Number 2 		448
Slide Number 3 		449
Differences between proton and photon planning 		450
Unfair comparison 		451
Slide Number 6 		452
Slide Number 7 		453
Radiation Production 		454
Fundamental Difference in Penetration 		455
Energy lost = Dose deposition 		456
Passive vs. active particle beam delivery 		457
Skull base chordoma 		458
Sacrum chordoma 		459
Prostate 		460
Slide Number 15 		461
Slide Number 16 		462
Slide Number 17 		463
Dealing with uncertainties in TP 		464
Clinical example for dose distortion 		465
Treatment plan robustness 		466
Robust beam arrangement 		467
Robust beam arrangement 		468
Beam specific margins 		469
Robust optimisation 		470
Robustness considerations e.g. Prostate 		471
Penumbra 		472
Penumbra 		473
Slide Number 29 		474
CT artefacts due to metallic implants 		475
RBE protons 		476
SBO (SFUD) and MBO (IMPT) 		477
SBO vs MBO example prostate case 		478
Optimization strategy 		479
Field matching 		480
Particle planning basics 		481
Potential of ART 		482
CIBT wrt PT: Some important differences for TP 		483
CIBT wrt PT: Some important differences for TP 		484
C vs p: Skull base 		485
C vs p: Sacrum 		486
Some practical aspect in ion beam planning 		487
Some practical aspect in ion beam planning 		488
Conclusion 		489
15Prostate case_Estro course ATP_2016_DvdBongard 		490
Slide Number 1 		490
Introduction Case 2: Prostate 		491
Mr R, 80 years old 		492
Prostate biopsy 		493
Mr R, 80 years old 		494
Gleason score 		495
Mr R, 80 years old 		496
Mr R, 80 years old 		497
FLAME trialFocal Lesion Ablative Microboost in prostatE cancer 		498
FLAME trialFocal Lesion Ablative Microboost in prostatE cancer 		499
Prostate - RT planning and position verification 		500
RT planning 		501
Planning-CT – fiducial gold marker 		502
Planning-CT and -MRI 		503
Planning-CT and –MRIChanges in rectal and bladder filling 		504
Functional MRI – prostate tumor (GTV2: 95 Gy) 		505
MRI – special case 		506
Prostate RT – Organs at risk + FLAME constraints 		507
Prostate planning – session objectives 		508
16.Case2planning aspects Prostate ESTRO 		509
Slide Number 1 		509
Slide Number 2 		510
Slide Number 3 		511
Slide Number 4 		512
some suggestions 		513
16a.Prostate case discussion v1.0_2016_TP_PDF 		514
Slide Number 1 		514
Prostate case discussion 		515
Clinical details 		516
Switch to Oncentra revue 		517
Individual planning session 		518
Which is the ‘best’ plan? 		519
17.Basic principles of rotational IMRT planning 		520
Basic principles of rotational IMRT planning 		520
In my institute 		521
Rotational IMRT not really new 		522
Slide Number 4 		523
Slide Number 5 		524
Slide Number 6 		525
Slide Number 7 		526
Slide Number 8 		527
So…. 		528
So how does is work in practise? 		529
Slide Number 11 		530
Slide Number 12 		531
Slide Number 13 		532
Static IMRT vs VMAT - Conceptual issues 		533
IMRT vs. VMAT - Conceptual differences 		534
Static IMRT 		535
VMAT 		536
IMRT vs. VMAT - Conceptual differences 		537
Slide Number 19 		538
Slide Number 20 		539
Slide Number 21 		540
Slide Number 22 		541
Slide Number 23 		542
Slide Number 24 		543
Slide Number 25 		544
Slide Number 26 		545
Alternatively: 		546
Slide Number 28 		547
So ….. 		548
RapidArc single arc versus double arc 		549
Slide Number 31 		550
Slide Number 32 		551
rotational cone beam IMRT vs static IMRT 		552
Slide Number 34 		553
Slide Number 35 		554
Conclusions 		555
18.ESTROATP_VanHerk_margins_final 		556
Slide Number 1 		556
Geometric uncertainties and how to deal with them 		557
Problems in radiotherapy: 		558
How can we solve this problem ? 		559
Image Guided Radiotherapy 		560
IGRT Technologies 		561
IGRT is brilliant ! 		562
Nomenclature 		563
EPID dosimetry QA to catch gross errors: used for all curative patients at NKI 		564
Gross errors detected in NKI 		565
What happens in the other 99.6% ? 		566
Motion counts? Prostate trial data (1996) 		567
The major uncertainties not solved by IGRT 		568
Delineation variation: CT versus CT + PET 		569
Are prostate markers perfect ? 		570
Intra-fraction motion: CBCT during VMAT 		571
Intra-fraction motion: CBCT during VMAT 		572
Slide Number 18 		573
Analysis of uncertaintiesKeep the measurement sign! 		574
Demonstration – errors in RT 		575
Slide Number 21 		576
Slide Number 22 		577
Slide Number 23 		578
Slide Number 24 		579
Slide Number 25 		580
2.5S + 0.7s is a simplification 		581
Practical examples 		582
Prostate: 2.5 S + 0.7 s 		583
Prostate: 2.5 S + 0.7 sNow add IGRT 		584
Lung planning target volume concepts 		585
Image selection approaches to derive representative 3D data 		586
Very clear lung tumor: classic RT 		587
Very clear lung tumor: IGRT hypo 		588
Planned dose distribution: hypofractionated lung treatment 3x18 Gy 		589
Realized dose distribution with daily IGRT on tumor (no gating) 		590
Clinical results with mid-V 		591
But what about the CTV ? 		592
Slide Number 38 		593
Conclusions 		594
Slide Number 40 		595
19.Molecular imaging RT UN 		596
Slide Number 1 		596
Molecular imaging in radiotherapy 		597
Medical imaging in radiation oncology 		598
Types of medical imaging 		599
Q1: In your center, do you use functional imaging for radiotherapy planning? 		600
Q2: How do you / would you use functional imaging for radiotherapy planning? 		601
Imaging literature, example PET 		602
Imaging literature, example PET 		603
FDG-PET/CT in diagnosis of solid tumors 		604
SPN: probability of malignancy 		605
Medical imaging in radiation oncology 		606
Slide Number 12 		607
Imaging for GTV delineation 		608
Molecular imaging for GTV delineation 		609
Reduction of IOV by new imaging methods 		610
Slide Number 16 		611
Slide Number 17 		612
Slide Number 18 		613
Slide Number 19 		614
Slide Number 20 		615
Slide Number 21 		616
Slide Number 22 		617
CTV: nodal spread 		618
Diagnostic accuracy of FDG-PET/CT in N-staging of NSCLC 		619
Slide Number 25 		620
Slide Number 26 		621
Slide Number 27 		622
PET-Plan Study: diagnostic expert-panel 		623
PET-Plan Panel:overall observer agreement by phase 		624
Slide Number 30 		625
Are you sure about your finding? 		626
Imaging for RT-planning: soon before treatment! 		627
Medical imaging in radiation oncology 		628
Cone-Beam CT 		629
Imaging for adaptive radiotherapy 		630
Slide Number 36 		631
... dose painting 		632
PET in RT planning: beyond GTV 		633
Slide Number 39 		634
Slide Number 40 		635
Prediction of local recurrence 		636
Prediction of NT-reactions? 		637
Response prediction during RT? 		638
„cooking recipe“ for the translation of new imaging modalities in radiation oncology 		639
Medical imaging in radiation oncology 		640
Morphological assessment of response 		641
“Functional” response assessment 		642
643
20.MRI in treatment planning_PDF 		644
Slide Number 1 		644
MRI in treatment planning 		645
Introduction:MRI – why, where, when? 		646
Introduction:MRI – why, where, when? 		647
Introduction:MRI – why, where, when? 		648
Introduction:MRI – why, where, when? 		649
Functional imaging modalities in MRI 		650
DWI images 		651
DWI images – ADC maps 		652
DWI images – ADC maps 		653
DWI images – ADC maps 		654
DWI images – ADC maps 		655
DWI images – ADC maps 		656
DWI images – ADC maps 		657
Diffusion tensor imaging - DTI 		658
Diffusion tensor imaging - DTI 		659
Diffusion tensor imaging - DTI 		660
Spectroscopic Magnetic Resonance 		661
Perfusion weighted images - PWI 		662
Perfusion weighted images - PWI 		663
Perfusion weighted images - PWI 		664
Perfusion weighted images - PWI 		665
Perfusion weighted images - PWI 		666
New MRI imaging modalities and radiotherapy planning 		667
New MRI imaging modalities and radiotherapy planning 		668
1. MRI for targeting: prostate 		669
1. MRI for targeting: prostate 		670
1. MRI for targeting: prostate 		671
1. MRI for targeting: prostate 		672
1. MRI for targeting: cervix 		673
1. MRI for targeting: cervix 		674
1. MRI for targeting: cervix 		675
1. MRI for targeting: brain 		676
1. MRI for targeting: brain 		677
1. MRI for targeting: brain 		678
1. MRI for targeting: brain 		679
1. MRI for targeting: brain 		680
1. MRI for targeting: brain 		681
New MRI imaging modalities and radiotherapy planning 		682
2. Direct planning on MRI images 		683
2. Direct planning on MRI images 		684
2. Direct planning on MRI images 		685
2. Direct planning on MRI images 		686
2. Direct planning on MRI images 		687
2. Direct planning on MRI images 		688
2. Direct planning on MRI images 		689
2. Direct planning on MRI images 		690
2. Direct planning on MRI images 		691
2. Direct planning on MRI images 		692
2. Direct planning on MRI images 		693
2. Direct planning on MRI images 		694
2. Direct planning on MRI images 		695
New MRI imaging modalities and radiotherapy planning 		696
MR-Linac 		697
MR-60Co 		698
MRI – 60Co: imaging features 		699
MRI – 60Co: imaging features 		700
MRI – 60Co: imaging features 		701
Slide Number 59 		702
Slide Number 60 		703
Slide Number 61 		704
New MRI imaging modalities and radiotherapy planning: conclusions 		705
New MRI imaging modalities and radiotherapy planning: conclusions 		706
Slide Number 64 		707
22.Advanced planning strategies for lung tumours (physical aspects)_pdf 		708
Advanced planning strategies for lung tumours physical aspects 		708
Why use IMRT in lung 		709
Why use IMRT in lung 		710
Why not use IMRT in lung 		711
Why not use IMRT in lung 		712
Why not use IMRT in lung 		713
Why not use IMRT in lung 		714
Slide Number 8 		715
Slide Number 9 		716
So forget about IMRT for lung if you don’t have these fancy tools? 		717
Key findings: 		718
Slide Number 12 		719
Slide Number 13 		720
Slide Number 14 		721
Why? 1 		722
Why? 2 		723
So ……. 		724
IGRT (not addressed in this course) is key here 		725
Slide Number 19 		726
Baseline shifts 		727
4D CBCT + GTV Contour 		728
Apply Correction 		729
Conclusions 		730
22.advanced planning strategies lung_pdf 		731
Slide Number 1 		731
Relationships between 3D dose distributions and clinical toxicities - Chest 		732
Normal tissues in the chest 		733
IOV in NT contouring: impact on dose calculation and plan optimisation 		734
Dose limits for normal tissues in the chest 		735
Esophagus: acute reactions 		736
Acute esophagitis: dose/volume effects 		737
Esophagus: late reactions 		738
Esophagus: planning constraints 		739
Esophagus: anatomy 		740
Esophagus: contouring 		741
Esophagus: geographic miss 		742
Find the esophagus 		743
Find the esophagus 		744
Find the esophagus 		745
Find the esophagus 		746
Lung (RILD) 		747
RILD: influence factors 		748
RILD: corelation between MLD and probability of symptomatic pneumonitis 		749
Slide Number 20 		750
Slide Number 21 		751
Lung: planning constraints I 		752
Lung: what about low doses? 		753
Lung: what about low doses? 		754
Lung: planning constraints II 		755
Lung: contouring 		756
Spinal cord 		757
Spinal cord: planning constraints 		758
Spinal cord: contouring 		759
Heart 		760
Heart 		761
Heart: planning constraints 		762
Heart: Delineation 		763
Heart: contouring 		764
Slide Number 35 		765
Bone 		766
Slide Number 37 		767
Brachial plexus 		768
Brachial plexus: toxicity 		769
Brachial plexus: planning constraints 		770
Contouring the brachial plexus 		771
Contouring the brachial plexus 		772
Thanks to: 		773
23.Lisbon APS lung case UN 		774
Slide Number 1 		774
Case 3 (lung) 		775
Slide Number 3 		776
Slide Number 4 		777
Slide Number 5 		778
Slide Number 6 		779
Slide Number 7 		780
24.Case2planning aspects T3 LungESTRO 		781
Slide Number 1 		781
Slide Number 2 		782
Slide Number 3 		783
Slide Number 4 		784
Slide Number 5 		785
Slide Number 6 		786
Slide Number 7 		787
Slide Number 8 		788
Slide Number 9 		789
24a.Lung case discussion Cambrige_pdf 		790
Slide Number 1 		790
Lung case discussion 		791
Slide Number 3 		792
Slide Number 4 		793
Slide Number 5 		794
Which is the ‘best’ plan? 		795
Slide Number 7 		796
Which is the ‘best’ plan? 		797
Switch to Oncentra revue 		798
Individual planning session 		799
25.ESTROATP_VanHerk_Sharpe_ConceptsAdaptive_final 		800
Slide Number 1 		800
Adaptive radiotherapy 		801
What is ART? 		802
ART Concepts 		803
Adaptive Concept 		804
Slide Number 6 		805
Slide Number 7 		806
Slide Number 8 		807
Slide Number 9 		808
When to correct ? 		809
Adaptive Radiation Therapy 		810
The Evolving Role of IGRT 		811
Initial PTV 		812
Confidence-Limited PTV (cl-PTV) 		813
Volume Difference: PTV vs cl-PTV 		814
Initial PTV & cl-PTV Do NOT Overlap 		815
Reality check: setup error pattern 		816
Adaptive radiotherapy 		817
Adaptive radiotherapy (naïve summary after 5 fractions) 		818
Naïve running estimates 		819
Slide Number 21 		820
Methods: average prostate 		821
Slide Number 23 		822
Results 		823
Slide Number 25 		824
Differential Variability 		825
Benefits of Daily IG-IMRT 		826
Tumour Regression 		827
Summary 		828
26.Library planning 		829
Library planning 		829
Slide Number 2 		830
plan of the day 		831
issues with library planning delivery 		832
potential tumour sites for online adaptive strategies 		833
potential tumour sites for online adaptive strategies 		834
potential tumour sites for online adaptive strategies 		835
Slide Number 8 		836
Slide Number 9 		837
Slide Number 10 		838
Slide Number 11 		839
Slide Number 12 		840
potential tumour sites for online adaptive strategies 		841
Slide Number 14 		842
Slide Number 15 		843
Slide Number 16 		844
Slide Number 17 		845
Bladder IGA 		846
Slide Number 19 		847
2 CT scans 		848
automated planning 		849
automated planning 		850
Slide Number 23 		851
dose wall maps of voided and full bladder plans 		852
Slide Number 25 		853
Slide Number 26 		854
Slide Number 27 		855
Conclusions 		856
27.ESTROATP_VanHerk_probplan_final 		857
Probabilistic planning 		857
Slide Number 2 		858
Variability in Repeated 4D CBCT 		859
Slide Number 4 		860
Uncertainty management: Probabilistic IMRT planning without margin 		861
Random errors & breathing 		862
Statistical Model of Breathing Motion 		863
Variability in Motion Day-to-Day Revisted 		864
Variability in Motion Day-to-Day Revisited 		865
Variability in Motion Day-to-Day Revisited 		866
Clinical Lung Case 		867
Slide Number 12 		868
Slide Number 13 		869
How DVH cost functions are calculated 		870
Slide Number 15 		871
Inclusion of uncertainties in plan optimization 		872
Robust vs probabilistic optimization 		873
Confidence level of objective functions 		874
Materials and Methods 		875
Objectives for treatment plans 		876
Effect of probabilistic planning 		877
Results 		878
Slide Number 23 		879
Probabilistic dose painting `by numbers' 		880
Conclusions 		881
28.Dose painted planning 		882
Dose painted planning 		882
The vision is clear 		883
Slide Number 3 		884
Slide Number 4 		885
Slide Number 5 		886
Slide Number 6 		887
Hypoxia Dose Painting Trail in Tübingen, Germany 		888
the FLAME trial: Focal Lesion Ablative Microboost 		889
Commercial planning systems do not support dose painting 		890
How? 		891
How? 		892
Slide Number 12 		893
How? 		894
Slide Number 14 		895
How? 		896
How? 		897
How? 		898
thresholding might be tricky 		899
How? 		900
Treatment plan evaluation 		901
Slide Number 21 		902
Slide Number 22 		903
Slide Number 23 		904
29.ESTROATP_VanHerk_defimagereg_fina 		905
Rigid and deformable registration 		905
Image registration 		906
Degrees of Freedom 		907
Demo rigid registration 		908
Deformation vector fields 		909
Deformable registration example 		910
Slide Number 7 		911
Prostate MRI w/wo Endo Rectal Coil 		912
Slide Number 9 		913
QA methods 		914
4D Phantoms 		915
Registration of anatomically realistic phantom in pelvis 		916
Natural Fiducials 		917
Results: Lung 4D CT (22)% Bifurcation Points 		918
Lung deformable registration easy ? 		919
Slide Number 16 		920
Slide Number 17 		921
Analysis of variance Observer places O1, Observer places O2Computer places O3 		922
Results: head and neck CT-CBCT 		923
Can you see all anatomical changes ? 		924
Easy deformable registration of the bladder? 		925
The bladder is a balloon in a box with stuff – it expands isotropic constrained by the organs around it 		926
Landmark validation of contour-based bladder registration 		927
Registration of shrinking tumor ? 		928
Overconfidence in commercial systems 		929
Conclusions 		930
Thank you for your attention! 		931
30.Introduction Case 4 Bilateral oropharaynx_pdf 		932
Slide Number 1 		932
Introduction to Case 5: Bilateral Oropharynx 		933
Staging 		934
HPV status (needed for prognosis) 		935
PTV prescription: SIB treatment 		936
Slide Number 6 		937
Slide Number 7 		938
Slide Number 8 		939
Slide Number 9 		940
Recommendations for IMRT use 		941
OARs constraints 		942
OARs constraints 		943
OARs constraints 		944
Parameters for clinical outcome: Salivary glands 		945
Mean dose to both parotids 25 Gy 		946
Mean dose to both parotids 35 Gy 		947
OARs constraints 		948
OARs constraints 		949
Parameters for clinical outcome: Salivary gland 		950
OARs constraints/objectives 		951
Replanning H&N IMRT patients 		952
Replanning H&N IMRT patients 		953
Replanning H&N IMRT patients 		954
Replanning H&N IMRT patients 		955
Slide Number 25 		956
Slide Number 26 		957
Patient monitoring: challenges for replanning 		958
Patient monitoring: challenges for replanning 		959
Slide Number 29 		960
30a.Planning aspects Head and Neck ESTRO 		961
Slide Number 1 		961
Slide Number 2 		962
Clinical example 		963
Conventional IGRT Workflow 		964
IGART Workflow/Closed loop principle 		965
How to finally evaluate? 		966
ART for head and neck cancer 		967
Results - adaptation vs non-adaptation 		968
Slide Number 9 		969
Control Scan after 10 fractions 		970
CT1 + originial ROIs 		971
CT2 + new ROIs 		972
Deformations 		973
Initial plan on CT1&2 		974
Deformed dose on CT2 		975
Original plan CT1&2 		976
Old and new ROIs on CT2 		977
Slide Number 18 		978
Slide Number 19 		979
31.Conclusion_Planning aspects Head and Neck ESTRO 		980
Slide Number 1 		980
PTV prescription: SIB treatment 		981
OARs constraints/objectives 		982
Slide Number 4 		983
Bias dose 		984
Different scenarios 		985
32.Pareto front 		986
Slide Number 1 		986
Slide Number 2 		987
Slide Number 3 		988
What is the pareto principle 		989
Slide Number 5 		990
Slide Number 6 		991
Slide Number 7 		992
Sweeping the dose : dose shaping 		993
Slide Number 9 		994
Slide Number 10 		995
Slide Number 11 		996
Slide Number 12 		997
Slide Number 13 		998
Slide Number 14 		999
Mnemonic for Pareto front 		1000
The „manual“ way to get there 		1001
Slide Number 17 		1002
Slide Number 18 		1003
Slide Number 19 		1004
Slide Number 20 		1005
Slide Number 21 		1006
Slide Number 22 		1007
Slide Number 23 		1008
Slide Number 24 		1009
Slide Number 25 		1010
Slide Number 26 		1011
Slide Number 27 		1012
Slide Number 28 		1013
Slide Number 29 		1014
Slide Number 30 		1015
Slide Number 31 		1016
Slide Number 32 		1017
Slide Number 33 		1018
Slide Number 34 		1019
Slide Number 35 		1020
Slide Number 36 		1021
Slide Number 37 		1022
Slide Number 38 		1023
Slide Number 39 		1024
Slide Number 40 		1025
33.Physicist's perspective 		1026
Physicist’s perspective 		1026
Emerging topics 		1027
Automatic normal tissue segmentation 		1028
Slide Number 4 		1029
Slide Number 5 		1030
Slide Number 6 		1031
Slide Number 7 		1032
Slide Number 8 		1033
Summary 		1034
the planning time to complete a (complex) H&N case is typically 		1035
Slide Number 11 		1036
Slide Number 12 		1037
Slide Number 13 		1038
Slide Number 14 		1039
Slide Number 15 		1040
Slide Number 16 		1041
Slide Number 17 		1042
Slide Number 18 		1043
Slide Number 19 		1044
Complications 		1045
Clinical Favourability 		1046
Wish-list: Formalised DM 		1047
Slide Number 23 		1048
Slide Number 24 		1049
Slide Number 25 		1050
Slide Number 26 		1051
Slide Number 27 		1052
Slide Number 28 		1053
Slide Number 29 		1054
Slide Number 30 		1055
Slide Number 31 		1056
Slide Number 32 		1057
Slide Number 33 		1058
Slide Number 34 		1059
Slide Number 35 		1060
Slide Number 36 		1061
Slide Number 37 		1062
Slide Number 38 		1063
the times they are a changin’ 		1064
34.Doctor's perspective - Cambridge 2016 - v1.1 handout 		1065
Slide Number 1 		1065
The doctor’s perspective 		1066
Summary 		1067
Use the best tools for the job ! 		1068
Treatment volumes compared 		1069
Slide Number 6 		1070
Slide Number 7 		1071
Small dose differences matter 		1072
Marginal gains 		1073
Dialogue – a key component of happy planning 		1074
Dialogue – a key component of happy planning 		1075
Dialogue – a key component of happy planning 		1076
Multi-criteria optimisation (MCO) 		1077
Multi-criteria optimisation (MCO) 		1078
IMRT – Optimisation 		1079
Slide Number 16 		1080
Multi-criteria optimisation (MCO) 		1081
Multi-criteria optimisation (MCO) 		1082
Normal tissue response data 		1083
Normal tissue response data 		1084
Normal tissue response data 		1085
Normal tissue response data 		1086
Dose accumulation 		1087
Dose accumulation 		1088
Dose accumulation 		1089
DSM for highest accumulated dose compared with planned 		1090
DSM for lowest accumulated dose compared with planned 		1091
Dose accumulation 		1092
Dose accumulation 		1093
VoxTox - results 		1094
Dose accumulation 		1095
Individual variation in normal tissue sensitivity 		1096
Individual variation in normal tissue sensitivity 		1097
Individual variation in normal tissue sensitivity 		1098
Individual variation in normal tissue sensitivity 		1099
Individual variation in normal tissue sensitivity 		1100
Individual variation in normal tissue sensitivity 		1101
Individual variation in normal tissue sensitivity 		1102
Synergy from physics and biology 		1103
Convolving individual radiosensitivity & individual dose accumulation 		1104
Convolving individual radiosensitivity & individual dose accumulation 		1105
Doctor’s perspective 		1106
Doctor’s perspective 		1107
Doctor’s perspective 		1108
Slide Number 50 		1109
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