1. DOSE COMPARISON OF RIVAL PLANS
FOR CRANIO-SPINAL IRRADIATION
USING HELICAL TOMOTHERAPY
G.Guidi1
, M.Amadori2
, G.Tolento2
, P.Antognoni2
, E.Cenacchi1
, A.E.Francia1
,
L.Morini1
, C.Danielli1
, F.Bertoni2
, T.Costi1
1
Struttura Complessa di Fisica Sanitaria
2
U.O. Radioterapia Oncologica
Azienda Ospedaliero - Universitaria di Modena - Policlinico

2. diapositiva 2G.Guidi, M.Amadori, G.Tolento et.al.
Simulation and comparison : PAEDIATRIC (CRANIO-SPINAL)
Old Standard Treatment @ Modena
1. Linac 6MV
2. Prone Position
3. Multiple field junction
4. 3 Split-beam (1cm each day)
5. No-Coplanar Beam
6. Multiple Isocenter (No SSD=100cm)
7. PTV Margin 1cm
8. Conformal field
9. Portal verification of each junction
10.Procedure time 45-60 min
DVH Results
1. PTVTx=PTV+1cm
2. PTVTx: 90% dose prescription (Dp) @ 95%Vol
3. PTVTx: Max 115% Dp
4. PTV: 95%Dp @ 95%Vol
5. Lens < 5-10Gy
6. Kidneys V20<20% Vol
7. Lung V20<20% and V30<20%
8. Abdominal dose in Field : 70% Dp
PTV=CTV=GTV

3. diapositiva 3G.Guidi, M.Amadori, G.Tolento et.al.
Simulation using Tomotherapy: PAEDIATRIC (CRANIO-SPINAL)
Tomotherapy Simulation
1. Tomotherapy
2. Prone Position
3. No Multiple field junction
4. No Split-beam
5. No-Coplanar Beam
6. No Multiple Isocenter
7. PTV Evaluation
i. Margin 1cm
ii. Margin 0cm
8. High Conformal
9. MVCT verification and adjustment
10. Procedure time 20-30min
Tomotherapy vs. Linac
•Lung, Hearth, Liver, Eyes, and Kidneys less dose/volume; for Hearth and Liver decrease the DMax
•Optical Nerve : same Dmax but less dose/volume
•Lens: decrease the Dmax Dose (Using Complete Block Option)
•PTVTx shows that may be an extra margin to the GTV=PTV could help in case of misalignments
Clinical Implementation : Phase2/3
• Supine position
• Immobilization device
• Target and Margin definition
• Dummy Definition
• OAR objective
• Optimize verification time
• Optimize treatment time
• Analyze dosimetric accuracy
• Treat patients
DVH Results
1. PTVTx=PTV+1cm
2. PTVTx: 99% dose prescription (Dp) @ 100%Vol
3. PTVTx: Max 105-107% Dp
4. PTV: 100%Dp @ 100%Vol
5. Lens < 5-7Gy
6. Kidneys V20<20-25% Vol
7. Lung V20<10% and V30<2%
8. Abdominal dose in Field : 20% Dp

4. diapositiva 4G.Guidi, M.Amadori, G.Tolento et.al.
Multiple Plan Comparison and Integral Doses: PAEDIATRIC (CRANIO-SPINAL)
Competitive Plan Comparison (PTV vs PTVTx)
• Same plan prescription and constrains using Tomotherapy
• Same number of iterations
• Export Doses Matrix
• Comparing using Focal
• Evaluate the differences of the dose matrixes
Homogeneity and Integral Doses must be investigated
• Using Prone position and LINAC Beams, the integral doses seems to
be less (Using Tomo 5Gy at 70% of the Vol)
• It is possible to appreciate an increase of the low doses some
treatment regions (Lung, Kidney, etc…)
• Dedicate studies is been activated across Europe and Tomotherapy
centers to confirm or demonstrate no implication of the low doses
delivered with IMRT and Helical IMRT within secondary tumors

5. diapositiva 5G.Guidi, M.Amadori, G.Tolento et.al.
Comparison and results : PAEDIATRIC (CRANIO-SPINAL)
Comparison
1. 2 rivals plan
i. Plan 1: PTV=GTV
ii. Plan 2: PTVTx=GTV+1cm
2. Develop (“Adjust”) a software comparison using 3rd software (Focal/Xio)
3. Dose subtraction between plans
4. Plan on GTV+1cm guaranties adequate target coverage in cases of <1cm of mismatch during the setup
5. Plan on GTV+0cm does not give adequate target coverage in cases of <1cm of mismatch during the setup
i. Without any PTV margin the dose difference could be significant decreased (mean 10%):
i. 20%Dose @100% of the GTV
ii. 10% of Dose @ 90% of the GTV
iii. 5% of Dose @ 80 of the GTV Volume

6. diapositiva 6G.Guidi, M.Amadori, G.Tolento et.al.
Comparison of competitive plans : PAEDIATRIC (CRANIO-SPINAL)
Comparison
1. OAR analysis
i. Heart & Liver : 20% of the volume savings
ii. Lung : 20-40% of the volume savings

7. diapositiva 7G.Guidi, M.Amadori, G.Tolento et.al.
Comparison and Considerations : PAEDIATRIC (CRANIO-SPINAL)
Comparison
i. Kidneys : 10-20% of the volume savings
Tomotherapy Simulation for Cranio - Spinal
1. Dose accuracy estimation must be investigated
and validated, especially into the non
homogeneity interface and grids
2. Tomotherapy calculate on 256x256 matrix (eyes
and small volume could be calculate not
accurately as we are supposing)
3. Use a fine grid could be a trick, but the batch
beamlets and optimization estimation is very
higher to believe to do the plans in a days
4. We will try move to 512x512 matrix and verify if
there are any differences
5. Patients QA procedure are very long and
complicate for long patients and volumes, but is
possible in any position (Head, Lung and Cauda)
6. Roll, Pitch and Yaw are not corrected and could
change the patient dosimetry (Also TLI, TMI and
TBI could have same problems)
7. Using a completion procedure during the
treatment could be helpful to align and setup
correctly the patients during the treatment in
each part of the body, but doses overlap could
create problems
8. For sure Tomotherapy improve patients comfort
(supine and fast procedures) and the quality of
the treatments, but without a deep analysis of the
process, bias on the treatment could appear.
9. Less risk using Tomotherapy comparing with
multiple split field junctions using Linac in case of
hot spots
10. Machine Down could be a problem and a
solution with a Linac must be provided (Not all
center have 2 Tomotherapy) with the opportunity
to sum 3DCRT plans with any Tomotherapy Plan

8. diapositiva 8G.Guidi, M.Amadori, G.Tolento et.al.
Today
ADVANTAGES AND
DISADVANTAGES
• Supine
• Faster
• Comfortable
• Safety (No beam junctions or couch
rotation and film exposition)
• Accurate setup using MVCT but an
extra doses to consider
• Accurate dose calculations (Lens
seems calculates not accurately
relatively to the images down
sampling)
• Procedures time: 20-30 Min
• Integral dose must be evaluate
accurately, especially for paediatric
patients
• Lateral Dummy ROI with directional
block option activate can help to
control the doses, but the DVH not
shows real volumes and could get in
trouble the doctors (New release will
resolve the problems)
• In-homogeneity to the Target is bigger
using lateral dummy at the arms, but
decrease the integral doses
• Lung and Kidney sparing is evident
• Lens has similar same problems
during calculation
• Abdominal doses is comparable with
the Linac techniques using the dummy
ROI
.... NOT ANYMORE NIGHTMARE FOR PHYSICIST AND DOCTORS THINKING TO THE JUNCTION...

9. diapositiva 9G.Guidi, M.Amadori, G.Tolento et.al.
Conclusion
• Cranio-Spinal using Tomotherapy provide better comfort and safety procedures compared with the Linac
Junctions techniques
• Tomotherapy has some disadvantages associated with integral doses that must be carefully analyzed
especially for Paediatric treatment.
• Using lateral Dummy ROI can be introduced some tricks to optimize better the plan, but should be
evaluated carefully the OARs volume
• A better PTV coverage and OARs sparing and dose uniformity distribution is indisputable using
Tomotherapy
• Anyway, Tomotherapy allows to treat patients in less time and with a better setup verification
• No multiple junction and split beams can guaranties an improve of the safety procedures
• A 3th part software analysis (Using Focal) has showed the opportunity to compare multiple Plans and
define the better margin expansion and the best plan for the patients, based on quantitative analysis, but
also has shows some limitation referable to the images down sampling (e.g. Lens dose and volume
calculation)
• Unexpected machine down or maintenance could be create some problem if there isn’t a Tomotherapy
backup machine. Must be investigate the opportunity to create a 3DCRT plan using a different TPS and
sum the doses with the previous treatment delivered by Tomotherapy

10. diapositiva 9G.Guidi, M.Amadori, G.Tolento et.al.
Conclusion
• Cranio-Spinal using Tomotherapy provide better comfort and safety procedures compared with the Linac
Junctions techniques
• Tomotherapy has some disadvantages associated with integral doses that must be carefully analyzed
especially for Paediatric treatment.
• Using lateral Dummy ROI can be introduced some tricks to optimize better the plan, but should be
evaluated carefully the OARs volume
• A better PTV coverage and OARs sparing and dose uniformity distribution is indisputable using
Tomotherapy
• Anyway, Tomotherapy allows to treat patients in less time and with a better setup verification
• No multiple junction and split beams can guaranties an improve of the safety procedures
• A 3th part software analysis (Using Focal) has showed the opportunity to compare multiple Plans and
define the better margin expansion and the best plan for the patients, based on quantitative analysis, but
also has shows some limitation referable to the images down sampling (e.g. Lens dose and volume
calculation)
• Unexpected machine down or maintenance could be create some problem if there isn’t a Tomotherapy
backup machine. Must be investigate the opportunity to create a 3DCRT plan using a different TPS and
sum the doses with the previous treatment delivered by Tomotherapy