IMRT Basics: R. Alfredo C. Siochi, Ph.D. Juan Carlos Celi, PH.D

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The key takeaways are that radiation therapy has evolved from conventional techniques using multiple fixed fields to more advanced conformal and IMRT techniques which can better sculpt doses to the tumor while minimizing doses to surrounding healthy tissues.

Some of the limitations of conventional and conformal radiation therapy include difficulty achieving conformality to irregularly shaped targets and meeting ICRU criteria. It can also be challenging to treat multiple targets simultaneously or enable dose escalation with these techniques.

Some benefits of IMRT compared to conventional and conformal radiation therapy include the ability to better spare organs-at-risk, treat irregularly shaped targets, treat multiple targets simultaneously, enable dose escalation, and provide economic benefits from improved patient outcomes.

IMRT Basics

R. Alfredo C. Siochi, Ph.D. Juan Carlos Celi, Ph.D.

The Evolution of Radiation Therapy


Intensity Modulated Radiation Therapy (IMRT) is the logical evolution of Radiation Therapy, starting from the first fractionated irradiation of patients in a conventional way, evolving into a conformal radiation therapy model, when automatic field sequencing and controlled conformal treatments were developed as a long way to achieve better QA of the radiation therapy process, and finally arriving at modulation of the beam for higher conformality. This evolution can be interpreted as the natural path from 1D treatments to a full 3D treatment process.
Conventional Radiation Therapy (external) Basic Advanced Conformal Radiation Therapy (external) Basic Advanced Intensity Modulated Radiation Therapy Basic Intermediate Advanced

Conventional Radiotherapy Basic 2 to 4 fields blocks and wedges Virtual Wedges MLC shaped fields 4 fields ~15 min. ICRU-50 concepts difficult to achieve Faster ICRU-50

Advanced

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Figure 2 - Conventional Radiotherapy

PTV GTV CTV

Contour Isodoses Target

Conformal Radiotherapy
Not a new concept: 1950-60 Proimos and Takahashi. Main idea: high doses to the tumor; minimum doses to the normal tissues. Purpose: to conform selected isodoses around the tumor and avoid critical structures.
Conformal Radiotherapy
Several fields (6 - 10) Comparative analysis - DVH, max. and min. doses - Average doses - Biological effect doses MLC shapes, wedges PRIMEVIEW: Automatic Field Sequencing automatic transition verification control

Basic

Treatment time Precision Doses

Figure 1 - Evolution of External Beam Radiation Therapy

Advanced

Conventional Radiotherapy
Based on the combination of several fields at different gantry angles, conventional treatments are still in use for several clinical applications. In order to achieve conformality, blocks and wedges are applied to the original fields. ICRU criteria are in many situations difficult to comply. To optimize the treatment process, MLC shaped fields were introduced and later with automatic wedges (virtual wedges).

Treatment time Accuracy QA

Figure 3 - Conformal Radiotherapy

IMRT Basics

Conventional vs. Conformal

Conventional vs. Conformal

68 Gy 60 Gy 50 Gy 30 Gy

Figure 4 - Conformal vs. Conventional: better isodose conformity, less dose to the normal tissues.

Figure 5 - IMRT: sculpt the doses (isodoses) to the tumor, avoiding the surrounding healthy tissues.

Intensity Modulated Radiotherapy


As described by Tubiana M, Eschwege F, Acta Oncol 2000; 39(5):555-67 Conformal radiotherapy (CRT) is based on three hypotheses: a higher rate of local control may improve the survival rate; dose escalation may increase tumor control; delivery of higher doses by decreasing the incidence of late effects. These postulates are now supported by several clinical data ... However, there are situations for which 3D-CRT cannot produce a satisfactory treatment plan because of complex target volume shapes or the close proximity of sensitive normal tissues. This is why intensity-modulated radiation therapy (IMRT) was introduced. Its aim is to overcome the limitations of 3D-CRT by adding modulators of beam intensity to beam shaping. IMRT can achieve nearly any dose distribution ...

The Siemens IMRT Approach


Improved verification, accuracy and efficiency for increased delivery safety, the Cinematic IMRT approach of segmental techniques is based on: Encrypting algorithms Utilization of optimization tools.

What is Intensity Modulation?


Intentionally non-uniform fluence distribution. Defines patient result, not method of delivery. IMRT is 3-D treatment delivery of a 3-D plan by modifying the intensity across each beam in complex ways. Methods: compensators, wedges, dynamic, static, cinematic

IMRT: Intensity Modulation of the Beam


3D CRT NO IMRT 3D IMRT

Why IMRT?
To spare organs-at-risk For irregular shaped targets To treat multiple targets simultaneously To enable dose escalation To treat regions with prior radiation

In the interior of the shaped field, the doses are homogeneous. Qualitatively conforms to the shape of the target and minimizes dose to critical structures through selection of beam directions and beam shapes.

In the interior of the shaped field, the doses are heterogeneous, for dose modulation. Produces dose distributions that conform tightly to the 3D shape of the target by varying the beam intensity across the shaped fields

Economic Benefits of IMRT


Incremental patients from current patient base New clinical applications for radiotherapy Improved reimbursement profile Optimal utilization of existing equipment
4 IMRT Basics

Figure 6 - IMRT, a higher level of modulation

What is an Intensity Map?


An intensity map is a matrix of pencil beams with different weights and different intensity levels (relative units). It reflects the sculpted desired dose for each field and their combination. The initial continuous map is transformed into segments with different intensity levels. That is the basis of MLC segments.

Figure 7 - Examples of continuous and discrete intensity maps

Fluence or Intensity Modulation?


Strictly speaking, it is the fluence distribution that is modulated by the motion of jaws and leaves, but the term intensity modulation has appeared in the literature ... (Medical Physics 21 (7) May 1996)

Figure 9 - Conformal avoidance and dose escalation. From: T. Bortfeld, Optimized Planning Using Physical Objectives and Constraints, Semin. Radiat. Oncol. 9: 20-34, 1999.

IMRT: modalities
By planning: Forward planned IMRT Aperture based IMRT Inverse planned IMRT Monte Carlo based IMRT By delivery systems: Multileaf Collimators MLC Micro-, Mini-, Virtual-Micro MLC Tomotherapy devices By treatment techniques: Segmented sequential (step and shoot) Cinematic sequential (Cinematic IMRT) Dynamic sequential (sliding window) Intensity Modulated Arc Therapy (IMAT) Tomotherapy

General Definitions
Figure 8 - Discrete Modulation of Fluences with an MLC

Why do it?
IMRT creates superior dose volume histograms compared to conventional RT. At the DVH, the separation between target dose and Organ at Risk (OAR) doses is greater. In theory, that allows for dose escalation to the target, if necessary. The concept of conformal avoidance takes place.

Static IMRT Nothing moves when the beam is on Fields with segmentation Also known as step and shoot method Dynamic IMRT Leaves (modifiers) move when the beam is on Fields with segmentation plus contribution of the doses between segments Sliding window Arc-therapy with IMRT

IMRT Basics

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