Image Guided Intensity Modulated Photon Radiation Therapy With Non-Invasive Immobilization for High Dose Treatment of Primary

Tumors of the Spinal Column

Yoshiya (Josh) Yamada MD FRCPC, Mark H. Bilsky MD, Michael Lovelock PhD, Joan Zatcky NP, Zvi Fuks MD
Departments of Radiation Oncology, Medical Physics and Surgery, Memorial Sloan-Kettering Cancer Center New York, New York

Why Paraspinal IMRT?

Vexing clinical problem:
Significant morbidity Spinal cord tolerance issues
Primary tumors Metastatic tumors Prior treatment

Tumor control may require radiation dose greater than cord tolerance

Radioresistant and Radiation Dose: Conventional XRT

Effective treatment

Metastatic
Sensitive Myeloma Lymphoma Moderately Breast Carcinoma Sensitive Moderately Colon Carcinoma Resistant NSCLCa

Primary
Ewings Sarcoma
Neuroblastoma

Superior Sulcus Tumors Osteogenic Sarcoma

Suboptimal Highly treatment Resistant Higher doses may result in spinal cord toxicity

Thyroid Carcinoma

Renal Cell Carcinoma

Sarcoma Melanoma

Chondrosarcoma
Chordoma

Dose Matters: XRT Failure Analysis

141 patients with chordoma and chondrosarcoma of the skull base/cervical spine Mixed proton beams 69 Co Gy (67 72) 26 failures 23% failed in prescribed dose region 58% failed in regions constrained by normal tissue tolerance 10% in surgical pathway 10% marginal miss

75% of failures occurred in areas with less than prescribed dose

JP Austin et al. Int J Rad Oncol Biol Phys 1993; 25: 439 - 444

Image-Guided Photon IMRT

Irradiating tumors to high doses beyond SC tolerance:
Accurate identification of target and normal structures Treatment planning Immobilization Verification Delivery

IMRT: An Alternative to Proton Beams ?

Ideally suited for concave dose distributions around the spinal cord Inverse treatment planning with constraints

Cord Sparing Dose Intensity Map

Primary Tumors (N=20)

Prescribed Dose PTV (cc) % PTV
Cord Max Cord Ave (%)

7000 cGy
153 cc

5940-7000 cGy
86-316 cc

90%
68% 31%

83-100%
14-75% 7-66%

Immobilization
Non invasive image guided cradle immobilization Thoracic and pelvic pressure plates Aquaplast mask Alpha cradle support MRI/CT compatible

Set up Reproducibility

Immobilization Performance
Immobilization determined by computing patient shift from start to end of treatment

Image Guided Verification: EPID

Digital portal image verification Surgical Hardware as Fiducial Markers Calculate necessary shift with image overlay

Image Guided Verification

Fiducials

2 D Image Guided Verification

Gold seed fiducials

2 D Image Guided Verification

Fiducial

3 mm lateral shift correction

2 D Image Guided Verification

Fiducial Match

3D Verification:Cone Beam CT
3-D to 3-D image matching Data for treatment plan modification Implanted fiducial markers not necessary Less than one minute to acquire images Automated registration and set up correction calculations Retrofit to existing LINACs

Cone Beam vs. Fluroscopic Images

CT CT Verification (OBI):
Direct 3D to 3D comparison Direct soft tissue visualization On table simulation: 3D data for treatment plan modification (weight loss, tumor responses etc)
Fluroscopic 3D Verification Indirect (2D to 3D) comparison Relies on bony landmarks or radio opaque markers Requires CT simulation for replan

Image Guided Verification 3D to 3D Matching

OBI Paraspinal Cone Beam Scan

Other Advantages of Cone Beam

Less radiation for position verification
Cone beam CT 4-6 cGy MV port film 2 cGy

Faster verification vs. portal imaging

Cone beam acquisition ~ 1 minute vs. multiple port films Automated correction algorithms

The Future with Cone Beam CT

Unleash the full potential of IMRT Reduce geometric uncertainties Accuracy: Redefine PTV Increase Biologic Effective Dose Hypofractionation/Single fraction radiotherapy Real time treatment planning/modification True 4 D Conformal Therapy

The Paradigm To Deliver Adequate Dose Safely

IMRT to spare the cord Immobilization to reduce motion uncertainties:
Radiation is given as intended to tumor and normal tissues

Verify isocenter position: Radiographic/Cone Beam CT

Correct for any set up errors +/- 1 mm treatment accuracy

Clinical Outcomes
N=20
Chondrosarcoma (5) Other Sarcoma (9) Chordoma (5) Desmoid (1)

Median age=60 years (29-79) Median follow up= 21 months (3-45)

FU with MRI every 3 months All patients followed until death

Local Control Primary Lesions

Local Control
100 90

Proportion Controlled

80 70 60 50 40 30 20 10 0 0 10 20 Months 30

80%

Proportion Surviving

40

50

Overall Survival
Survival
100 90

84%

Proportion Surviving

80 70 60 50 40 30 20 10 0 0 10 20 Months 30 40 50 P rop o rtio n Surviving

IMRT Complications
No significant toxicity Grade 2 mucositis in 2 patients No Clinical or Radiographic Evidence of Myelopathy/Radiculopathy/Plexopathy 80% of patients durable palliation of symptoms

IMRT Chondrosarcoma

1975: Chondroblastoma

12/00: Chondrosarcoma Severe biologic and radicular pain

2/7/01: Operation Gross total resection

IMRT Chondrosarcoma
6/02: Recurrence with left hand intrinsics and biceps 2-3/5
7/12/02: IMRT Tumor: 7080 cGy/38 SC: 5320 cGy 8/12/02: Complete motor recovery 4/24/03: Tumor shrinkage on MRI 9/24/04: Radiographically stable 6/02

Conclusions
High dose photon radiotherapy sparing the spinal cord is feasible with IG IMRT Radioresistant or inadequate doses? Highly accurate and reliable non invasive immobilization is possible for multiple fractions Preliminary clinical outcomes are favorable: Palliation of symptoms Radiologic control No significant toxicity