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Vol. 15 | No. 2 | August 2011
NEWS AND ADVANCES IN THE MANAGEMENT AND TREATMENT OF SERIOUS DISEASE
Canadian speed and efficiency with Elekta VMATPAGE 4
MEG reveals unseen brain injuriesPAGE 6
Elekta Integrity puts Baton Rouge center in controlPAGE 10
ClinicalView scans the literature for hot topicsPAGE 16
About the cover
Cancer Cell No. 3, (Acrylic on Canvas) by artist Angela Canada Hopkins. Why art depicting cancer cells? After losing her father to cancer, Angela sought to embrace the enemy in order to overcome it. With playful and spontaneous brush strokes she laid down a colorful conquest of cancerous matter. A bittersweet and therapeutic irony spilled out onto her canvas. According to the artist, “I use a pure and lively incorporation of acrylic on canvas to create galaxies of basic fatal structures studied at a microscopic level.” © Angela Canada Hopkins
In developing solutions to defeat cancer, we must always remember that the primary focus is the patient.
Experience the Elekta Difference.
Human Care Makes the Future Possible
Although Elekta is a cancer manage-ment company focused on developing technological solutions to defeat this disease, we must always remember that the primary focus is the patient. This may be a simple proposition, but as technologies and therapies evolve and improve, radiotherapy techniques are becoming increasingly sophisticated, requiring more time and skill to ensure delivery as prescribed.
As Elekta partners with customers to integrate the most advanced capabilities in our solutions, we must concurrently innovate to manage this complexity. Elekta simplifies the variables in planning, patient setup, treatment verification and delivery, to inspire you with greater confidence to define and raise the standard of human care. Each is designed and introduced with equal emphasis on sophistication and simplicity.
Simplifying our solutions serves another vital purpose, which is to ensure the utmost safety in the operation of our technology. The incorporation of product safety features such as hard interlocks and checklists are critical in mitigating errors. Our digital linear accelerators, for example, feature three tiers of safety to foster confidence in the delivery of the radiation dose.
Clearly, cancer management technology will never become less sophisticated – but using these solutions can indeed become simpler. This is the concept that informs the creation of the “blueprints” for our solutions. It is our way of managing complexity so you can focus on what matters most.
This issue of Wavelength features some examples of this approach to product development – I hope you enjoy reading about them!
Tomas PuuseppPresident and CEO of Elekta AB
3
Dear friends,Contents
Speed and Efficiency 4 with Elekta VMAT
Lifting the Veil – MEG 6 Images Subtle Brain Injury
Firmly in Control 10 with Integrity™
Elekta Around 12 the World
Integrity – Three Tiers 14 of Safety
Elekta Events 14 in your Region
Future of Radiation 15 Medicine Symposium
ClinicalView Scans 16 Important RT Trends
Nowhere to Hide 19 – SonoWand Invite™
The Elekta Clinical 20 Consortia Program
Get Your Clinic Featured 22 in Wavelength
Vol. 15 | No. 2 | August 2011
Published by Elekta | www.elekta.com
All letters, comments or suggestions for future articles, requests for reprints and permissions are welcome.
Contact Wavelength: Michelle Lee, Director, Global PR and Brand Management Tel: +1-770-670-2447 (time zone: Eastern Standard) | Email: [email protected]
Regulatory status of products: This document presents Elekta’s product portfolio. Certain products or functionality described may be works in progress or pending regulatory approval for certain markets.
Art. No. 1022328 © Elekta AB (publ). All mentioned trademarks and registered trademarks are the property of the Elekta Group. All rights reserved. No part of this document may be reproduced in any form without written permission from the copyright holder.
’’We could use the time savings from
the VMAT cases to offer more complex, more conformal techniques to more patients.”
4
W inding up a few months of Elekta vmat™ testing, physicists at Odette Cancer Centre, part of Sunnybrook Health Sciences Centre
(Toronto, Ontario, Canada), have confirmed that vmat offers significant benefits for their patients and have begun using the delivery technique for patients with prostate cancer. Odette’s clinical vmat use was the culmination of intense evalua-tions, including a plan comparison of Elekta vmat, imrt and helical delivery methods.
Melanie Davidson, ph.d., and Gordon Chan, ph.d., Odette medical physicists, recognized the potential of vmat from the literature and in 2010 determined to evaluate how it could benefit the Cancer Centre.
“When we consider implementing new technology, we evaluate whether it has the potential to offer either a dosimetric or a delivery advantage over existing techniques offered within our clinic,” Dr. Davidson says. “The suggestion that vmat could offer increased efficiency in treatment delivery interested us not only because it could increase patient throughput, but because it also would free up time on our treatment machines to offer igrt and more special-ized techniques to a larger subset of patients.”
Comparative study on delivery efficiency
As early as 2009, she led a comparative vmat, imrt and helical tomotherapy planning study for prostate and head-and-neck cancers. The study, facilitated by a loan of vmat software by Elekta and of the SmartArc module by Philips, was the subject of a white paper available for download on the Elekta website. (see white paper, opposite page)
A follow-up planning study sought to quantify differences in treatment delivery efficiency and dosimetry between step-and-shoot imrt, vmat and helical tomotherapy for prostate treatment.1
“We were looking at different prostate volumes of increasing sizes and complexity, including localized, locally advanced and post-operative prostate targets,”
she notes. “We found that vmat could yield improve-ments in delivery efficiency without compromising the dosimetric quality of the prostate treatments when compared to imrt and helical tomotherapy.”
Ramping up to VMAT
The positive results of the study comparing delivery methods convinced Odette management that vmat had the potential to offer clinical and workflow benefits. Dr. Davidson and Dr. Chan then proceeded methodically to confirm that Odette had the appropriate funding, treatment planning, quality assurance (qa) procedures and tools, and staffing in place to ensure the vmat service’s success.
The next phase in the vmat implementation process involved the commissioning and testing of the technical aspects involved in vmat delivery. An evaluation of how well the treatment planning system could predict dose distributions compared to patient-specific measurements was also conducted to establish criteria for acceptability of clinical vmat plans.
The machine and treatment plan qa process is still fairly intensive, according to Dr. Chan, but the time saved in treatment delivery should help compensate for that.
“That said, the machine qa process has been going very well and we have established preliminary standards for both machine and patient-specific plan qa,” Dr. Chan says. “However, these standards are evolving as we’re gaining more experience and confidence with vmat dosimetry and delivery. In the future, we are looking to streamline our machine qa processes and determine which tests are required, and what their frequency should be.”
First cases confirm speed gains
Odette is only at the dawn of its vmat service, but the experience of the first 12 patients has substanti-ated planning studies and phantom tests, Dr. Davidson observes.
“Seeing the 90 second single arc delivery that we typically achieve for a prostate case is pretty amazing compared to our standard 7-beam, 50 segment
Odette medical physicists Gordon Chan, ph.d., and Melanie Davidson, ph.d.
Figure 1. Dose distribution (in cGy colorwash) for one example prostate obtained when using (a) vmat, (b) Seven beam step-and-shoot imrt and (c) ht.
Speed and Efficiency with Elekta VMAT
5
step-and-shoot imrt prostate plans, which take roughly six minutes to deliver when using consolidated field sequencing,” she says. “Compared to helical tomother-apy, vmat prostate delivery times are 2-3 times faster.”
More complex cases such as head-and-neck cancers probably will involve more than one arc, increasing vmat delivery times, but according to Dr. Davidson, “I still think vmat will offer some time savings in treatment delivery compared to other techniques in more complex treatment volumes.”
She observed that employing a single-arc treatment simplifies the record-and-verify process on Odette’s mosaiq® emr from the Pinnacle treatment planning system.
Faster and simpler process
“Our standard 7-beam step-and-shoot imrt plan requires the import and verification of data transfer for seven beams to mosaiq,” she says. “Having a single vmat arc for a prostate case makes the process somewhat faster and simpler, so we do see some time-savings in that process.”
It’s too early to speculate on how delivery time savings will translate into increased patient volume per day, but Dr. Davidson is optimistic that total treatment times for prostate cases could be reduced.
“While we haven’t yet revised this in our clinic, I think that reducing treatment time slots for prostate patients being treated with vmat is not unreasonable,” she observes. “These time savings may eventually help us increase patient throughput and reduce patient wait times for commencing treatment. More importantly, perhaps, we could use that time savings from vmat to offer more targeted techniques to a broader patient population.” l
WHITE PAPER
Planning study compares delivery methodsIn the study, VMAT, 7-beam IMRT and helical tomo-therapy (HT) treatment plans were created for two patients with prostate cancer and three with head- and-neck cancer.
Plan quality and delivery efficiency were compared between the three techniques through extraction of dosimetric data and evaluation of treatment delivery parameters. Single arc VMAT plans were equal in quality to the IMRT and HT plans for the prostate cases. Two arcs were needed to develop VMAT plans for the head-and-neck cancers that were comparable in quality to the IMRT and HT plans.
Treatment times for VMAT were up to 3.5 times lower in prostate cases and 2-3.5 times lower in head- and-neck cases compared to IMRT.
Similarly, prostate cases required 10-30 percent fewer monitor units (MU) and head-and-neck cases required 20-80 percent fewer MU for VMAT delivery compared to IMRT. Treatment times decreased two-fold for VMAT plans compared to HT.
Download the complete white paper at: www.elekta.com/proof
BY THE NUMBERS
Odette Cancer CentreF Radiation therapy patients, annually: >6,000F Equipment: Four Elekta Synergy® (two with
VMAT), three Elekta Synergy® S (all with VMAT), one TomoTherapy® HiArt®, MOSAIQ® Oncology Information System, Pinnacle Treatment Planning
F Staff: 26 radiation oncologists, 15 physicists, 130 radiation therapists, dosimetrists, planners
References1) Davidson MTM, Blake SJ, Batchelar DL, Cheung P, Mah K. Assessing the role of volumetric modulated arc therapy (VMAT) relative to IMRT and helical tomotherapy in the management of localized, locally advanced and post-operative prostate cancer. Int. J. Radiation Oncology Biol. Phys., (Epub as of May 2011)
6
In 2005, u.s. Marine Corps Col. g.i. Wilson was riding in a Humvee convoy between Ramadi and Fallujah in Iraq, when his vehicle passed over a tire concealing an improvised explosive device (ied). The ied was triggered remotely, the result-ing blast tearing through the Humvee’s undercarriage, knocking the 58-year-old Wilson unconscious and severely wounding other soldiers in the vehicle.
Military doctors treated his concussion symp-toms, physical injuries and emotional stress (ptsd) and returned him to service. But after
returning to America in 2006, Col. Wilson experi-enced lingering memory and attention problems; he “just didn’t feel right.” Ultimately, a meg exami-nation showed that he had suffered a mild Traumatic Brain Injury (mtbi), a revelation that would pro-foundly improve his life. (See patient case, pg 9)
At the University of California San Diego (ucsd)and va San Diego Healthcare System, a team led by Ming-Xiong Huang, ph.d. and Roland R. Lee, m.d. is using magnetoencephalography (meg) to image active-duty military and civilian populations to diagnose mtbi and to differentiate mtbi from ptsd, as the conditions share many symptoms.
Magnetoencephalography (meg) reveals neuropathological impact of traumatic brain injury in soldiers and civilians.
* Partial list of symptoms: headaches, dizziness, anxiety, fatigue, apathy, depression, irritability, noise and light aversion, lack of patience, sexual inappropriateness, and problems with concentration, balance, sexual performance, memory, sleep, hearing and the senses of smell, taste, hearing and vision.
** Vector-based Spatio-Temporal analysis using L1-minimum norm.
Lifting the Veil
Ming-Xiong Huang, ph.d. Roland R. Lee, m.d.
PHO
TO: ED
DAR
ACK
7
While the causes of mtbi differ between the two groups – blast-induced for soldiers who served in Iraq and Afghanistan and a variety of accidents for civilians – the consequences are the same: sufferers experience one or more of a spectrum of cognitive/behavioral problems.*
The mtbi research project is funded by ongoing grants from the U.S. Department of Veterans Affairs. Their meg unit is a 306-channel Elekta Neuromag® system acquired in 2005.
Detecting subtle damage
“mtbi is a major health problem for military personnel and civilians,” says Dr. Huang, ucsd physicist and associate director of the ucsd Imaging Center. “mtbi or concussion are reported as an ‘invisible brain injury,’ because conventional imaging methods, such as x-ray, ct and mri don’t detect any physiological injury. This doesn’t mean there wasn’t damage – it’s just that the injury is too subtle to be detected with traditional imaging methods.”
This subtlety results from the size and nature of the injured anatomy. In mtbi, the damage is to a minute (>35 μm diam.) structure called an axon, a neural process in the brain’s gray matter that allows neurons to communicate with each other. While ct and mri are extremely sensitive modalities, they usually can’t resolve structures this small, and – unlike many tissues and pathology in the human body – axons aren’t suffused with blood, so their injury is poorly depicted on ct and mri.
In mtbi, axons have been damaged by sudden acceleration-deceleration and/or rotational forces. The resulting tissue injury involves axonal stretch-ing, disruption and ultimately nerve fiber separa-tion. This separation – or deafferentation – elimi-nates or interrupts nerve impulses, which leads to the cognitive and behavioral deficits in patients with mtbi.
MEG measures abnormal slow-waves
Drs. Huang and Lee are advancing pioneering research by Dr. Jeffrey Lewine, et. al., which showed that the
brains of mtbi patients generate abnormal low- frequency magnetic fields that can be measured and localized by meg.1 Normal neuronal activity yields frequencies above 8 Hz, while neuronal tissues injured by head trauma, tumors or stroke generate abnormal low-frequency (1-4 Hz) fields, also called “slow-waves.”
It was the ucsd meg team that linked slow-wave generation with the deafferentation caused by axonal injury.2
The team produced a more refined meg slow-wave localization technique, which they have used to examine 45 mtbi patients (23 blast-induced/ 22 non-blast) and 10 moderate tbi patients. Twenty-eight healthy subjects in a control group comprised a normative database.3
“The acquisition is the same as in a traditional meg study,” Dr. Huang notes. “It consists of a resting-state meg with the subject’s eyes closed, then an acquisition with eyes opened. The main difference is in how we analyze the data.”
Various solutions for analysis
The ucsd team developed a meg source imaging solution called vestal**. The vestal solution measures both focal and nonfocal sources of abnormal slow-waves and is entirely automated and operator-independent, which eliminates clinical bias.
vestal compared slow-wave measurements from the mtbi patients with subjects in the normative database.
“This is not simple subtraction, because normal subjects show very small amounts of slow-wave activity as well,” says Dr. Lee, ucsd radiologist and director of the ucsd Imaging Center. “vestal measures the power in the slow-wave energy range
Elekta Neuromag®
Magnetoencephalography (MEG) system for functional brain mapping. Clinicians and researchers are increasingly adopting the fast-growing technology of MEG for non-invasive investigations of the brain’s magnetic fields. Clinical research applications of MEG include such neurological and psychiatric disorders as autism, traumatic brain injury, memory and brain function, schizophrenia, depression, as well as various learning disorders, including dyslexia. Furthermore, MEG is extensively used in normal cognitive
functions that underlie memory and language.
’’For CT and MRI, mTBI detection
is no more than 10 percent, while DTI approaches 30 percent. MEG achieves a 90 percent detection rate for mTBI, and nearly no false positives.”
>>
8
of 1-4 Hz between the two groups. There is signifi-cantly more ‘slow-wave power’ in the mtbi patients compared with the healthy subjects.”
In many cases, Huang and Lee’s group corrobo-rated the presumed axonal injury in mtbi patients with diffusion tensor imaging (dti). dti is an mri technique that can detect the directionality of water molecules as they diffuse through tissues; random directionality is isotropic diffusion, while specific directionality is anisotropic diffusion. Highly-anisotropic diffusion is seen as water molecules traverse normal cerebral white matter fiber tracts – the information highways connecting brain regions.
“Abnormal meg slow-waves are generated from cortical gray-matter areas that connect to white-matter fibers with reduced dti fractional anisotropy due to axonal injury in patients with mtbi,” Dr. Huang explains. “Specifically, the reduced anisot-ropy in local white matter fiber tracts led to focal abnormal meg slow-waves from neighboring gray matter in mtbi.”
By itself, dti doesn’t fare much better at diagnos-ing mtbi than do ct and mri, Dr. Lee adds.
“For ct and mri, mtbi detection is no more than 10 percent, while dti approaches 30 percent,” he says. “meg achieves a 90 percent detection rate for mtbi, and nearly no false positives.”
Differentiating PTSD and mTBI is critical
As in Col. Wilson’s case, ptsd and mtbi symptoms overlap considerably, but treatments for each differ, because mtbi involves actual physiological injury to neural anatomy whereas ptsd is characterized by emotional and psychological trauma. Treating a soldier or civilian suffering from ptsd with psychiat-ric intervention and anti-anxiety medications would not target an unseen mtbi.4
“The mtbi symptoms would probably persist,” Dr. Lee says. “Cognitive therapies specifically directed at brain regions showing abnormal meg slow-wave activity due to mtbi might better address the source of the problem.”
MEG on the horizon
The ucsd meg team has embarked on a new project that will follow its first mtbi patients into their recovery period.
“We want to see how the improvement in clinical mtbi symptoms over time impacts on their meg slow-wave measurements,” Dr. Huang says. “In addition, several pharmaceutical companies are potentially developing new medications that target mtbi. We want to determine how meg could be used as a pre- and post-intervention tool to gauge the effectiveness of these drug therapies.” l
References1. Lewine JD, Davis JT, Sloan JH, Kodituwakku PW, Orrison WW Jr., 1999. Neuromagnetic assessment of pathophysiologic brain activity induced by minor head trauma. Am J Neuroradiol. 20, 857-866.
2. Huang, MX, Theilmann, RJ, Robb A, Angeles A, Nichols S, Drake A, D’Andrea J, Levy M, Holland M, Song T, Ge S, Hwang E, Yoo K, Cui L, Baker DG, Trauner D, Coimbra R, Lee RR, 2009. Integrated imaging approach with MEG and DTI to detect mild traumatic brain injury in military and civilian patients. J.Neurotrauma 26, 1213-1226.
3. Huang, MX, et al, 2011 (in press). An automatic MEG low-frequency source imaging approach for diagnosing mild and moderate TBI patients with blast and non-blast courses.
4. Magnetoencephalography (MEG) and Diffusion Tensor Imaging (DTI) for Differential Diagnosis in Mild TBI and PTSD. Presented by Mingxiong Huang (PhD): Integrated Research from VASDHS, UCSD and NMCSD. Navy and Marine Corps Combat & Operational Stress Conference 2010. “Taking Action, Measuring Results.”
BY THE NUMBERS
Traumatic Brain Injury (TBI) F The Centers for Disease Control (CDC) estimates
that each year 1.7 million Americans sustain a TBI, including concussions. Of those individuals, 52,000 die, 275,000 are hospitalized, and 1.4 million are treated and released from an emer-gency department.
F According to UCSD’s Dr. Huang, mild TBI (mTBI) represents about 85 percent of overall blast-induced TBI in the Iraq/Afghanistan combat theatres.
F Approximately 80 percent of all individuals with mTBI are symptom-free six to nine months post-injury as the brain regenerates neural connections. The remaining 20 percent experience long-term post-concussive symptoms and have a higher risk of additional neurological disorders, such as epilepsy and dementia.
F More at www.cdc.gov/Features/BrainInjury
History: 17-year-old male athlete who suffered three mtbi’s while playing football. The first and second concussions were separated by a few weeks, and the third occurred a few months later. After the first injury, the patient suffered headaches. After the second injury, he experienced headaches, dizziness and extreme fatigue while performing any mental task. Following the third concussion, he experienced pressure headaches, dizziness, fatigue, altered sleep, memory problems and changes in speech. Multiple ct and mri scans were negative. The meg results (left group) show abnormal slow-waves generated from two regions: 1) left column – left lateral superior-posterior temporal region, 2) right column – right inferior-temporal areas. The top, middle and bottom rows are lateral view, ventral view and middle view, respectively. dti (right) scans showed abnormal dti signal in the superior-posterior lobe of the left hemisphere (left column coronal and axial views). Abnormal dti signal is seen in the inferior-temporal lobe as part of the inferior longitudi-nal fasciculus of the right hemisphere (right column).
Huang et. al., J. NeuroTrauma; 26: 1213-1226.
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United States Marine Corps Colonel G.I. Wilson
read a book for five to 10 minutes, to reading for 15 minutes, then to 20 and 30 minutes. I actually started graduate school and my note-taking in class got better. The doctors encouraged me constantly to challenge myself, because exercising my brain would regenerate neural connections. This didn’t happen ‘overnight’ – I made slow, steady progress. But I always made progress.”
For Col. Wilson, the most critical revelation was that his cognitive and emotional symptoms had a physical cause.
“The uncertainty, the feeling that I was going nuts – it can drive you absolutely ‘batshit,’” he says. “Have you’ve ever heard the expression: ‘They’re working the wrong problem?’ Well, I would have been happy for a problem to work, but I didn’t know what it was. The meg study, and Drs. Baker and Huang and the ucsd meg team, defined the true issue and helped me work the right problem.”
Since returning from Iraq, Col. Wilson, now 64, has earned Masters degrees in security management and forensic psychology, and is pursuing a ph.d. degree in forensic psychology. l
PATIENT CASE
l usmc Col. g.i. Wilson’s mission in November 2005 was to assess the ied threat along a convoy route in a perilous region of Iraq. Ironically, Col. Wilson confirmed the threat the hard way. Back in the United States, the ied blast that wounded Col. Wilson and his men perpetuated itself in an array of persistent symptoms.
“I was having back pain, neck pain and head-aches,” he says. “I kept having my hearing and vision tested. X-rays and mri showed nothing – no injuries to my back or head. But I just didn’t feel right. I was having trouble concentrating, finding words and with my working memory – and there was a marked difference in my writing before and after. I had a feeling there was something wrong with me, but I didn’t know what it was. I was desperate at that point, because I thought I must be losing my mind.”
Col. Wilson retired in June 2006 and entered the va system. He met va San Diego Healthcare System psychiatrist Dewleen Baker, m.d. in 2007. After an initial comprehensive screening that acknowledged Wilson’s pre-existing ptsd, Dr. Baker referred him for a meg examination to determine if an mtbi was causing Col. Wilson’s cognitive symptoms.
The meg study clearly pinpointed abnormal slow-wave activity in the brain regions responsible for attention and memory encoding of novel information. Armed with this information, Dr. Baker substantially scaled back Col. Wilson’s dosages of anti-depressive and anti-anxiety drugs for ptsd and prescribed a full battery of vocational rehabilita-tion, pain management, speech and physical therapy and cognitive exercises and strategies to improve his working memory, learning and concentration.
“My improvements were slow, but gradual,” Col. Wilson reports. “I went from being able to
“Working the right problem”
Dewleen Baker, m.d.
meg scan of Col. g.i. Wilson showing abnormal slow- waves (above threshold) in the supramarginal gyri in the posterior parietal lobe and in the parahippocampal gyri (bilateral).
10
R adiation oncologists and medical physicists expect their treatment systems to do a lot these days and vmat is a perfect example.
In a single technique, radiation therapy moved from static to fully dynamic – with the gantry, mlc and collimator all moving simultaneously, and on-the-fly gantry speed and dose rate modulation throughout the vmat arc. vmat ushered in the kind of com-plexity that demands a robust control system.
Clinicians at Mary Bird Perkins Cancer Center (mbpcc, Baton Rouge, La., usa) recognized the challenges and opportunities that sophisticated methods present and decided to upgrade their Elekta Infinity™ linac with the Integrity™ control system.
“Mary Bird Perkins’ medical physics expertise lends itself perfectly to this type of early product implementation and testing with Elekta. We are pleased to be able to contribute to the evaluation of the Integrity control system which will ultimately benefit patient care,” says Todd Stevens, President and ceo, mbpcc.
Enhanced safety
Having used Integrity for seven months (editor’s note, by Aug. 2011), mbpcc medical physicist Jonas Fontenot, ph.d., reports on features of the new control system that enhance safety, the potential of mlc interdigitation and smoother, faster vmat.
Integrity employs three tiers of safety. The first
tier records and verifies the prescription received from mosaiq® ois and checks that all linac param-eters are set correctly. The second tier checks and controls mlc leaves, gantry, collimator and dose delivery every 40 milliseconds, ensuring that all parameters are in the correct position and the right dose is being delivered. Guardian, the third tier, supervises the proper operation of the other two tiers – verifying in real-time that the field currently being delivered matches the prescribed treatment param-eters. If a discrepancy occurs, Guardian will stop the treatment.
“I like that it’s not just one set of measures being deployed to ensure correct treatment delivery,” Dr. Fontenot says. “Another noteworthy feature of the Integrity functionality within the mosaiq envi-ronment is that during vmat, Integrity constantly captures delivery parameters and sends them back to mosaiq. These data then become part of the perma-nent electronic treatment record. We use an in-house utility to extract delivery data from the mosaiq data-base, analyze it and notify our technical staff of any anomalous treatment behavior. It’s a good example of the flexibility and transparency of Integrity, which enabled us to construct custom safety features.”
Complex leaf motion for complex cases
With interdigitation enabled by Integrity, mlc capabilities have caught up with the ability of the
Firmly in Control
Mary Bird Perkins Cancer Center (mbpcc) clinicians realize benefits of Elekta’s Integrity control system for patient safety, mlc interdigitation and vmat performance.
Jonas Fontenot, m.s., ph.d.
John Gibbons, ph.d., Chief of Clinical Physics
Squamous cell carcinoma of the left tonsilar fossa. Prescription doses were 7000cGy to the red colorwash, 5700cGy to the green. Both plans utilized identical plan-ning objectives, settings and optimization time. The only difference between the plans was mlc interdigitation.
11
treatment planning system to create fields with complex geometry. Because mlc leaves can move past one another (i.e., interdigitate), clinicians can employ island fields in difficult cases, such as those involving multiple targets. Dr. Fontenot is prospec-tively evaluating the impact that mlc interdigitate will have for enhancing treatment plan quality.
“Interdigitation is important not just for treating multiple targets – such as multiple brain mets – but also when there is a target geometry that consists of different dose objectives,” he observes. “For example, we may want to treat a primary target to 70 Gy and a nodal region to 57 Gy.”
Dr. Fontenot has found that in relatively simple target geometries, such as prostate cancer, mlc interdigitation won’t significantly improve plan quality, however it does make a difference in com-plex geometries, such as head-and-neck cancers.
“Plans constructed with mlc interdigitation for these targets appear to exhibit better target volume dose coverage and better target homogeneity than plans constructed without interdigitation,” he notes. (See figure page 10)
mbpcc plans to integrate interdigitation for all four of its Elekta linear accelerators when the latest Integrity release is introduced.
Quicker, smoother VMAT
Integrity supports Continuously Variable Dose Rate (cvdr), which allows the dose rate to be adjusted to its ideal mu value during delivery of both dynamic and vmat prescriptions. This option makes pre-scription delivery smoother and faster when compared to previous discrete dose rates.
“The additional dose rate options permit the control system to easily navigate complex dose modulation paths,” Dr. Fontenot explains. “Less vari-ability in gantry speed smoothes vmat arc motion.”
cvdr also has helped shave seconds off vmat arcs in mbpcc pre-clinical tests comparing the previous generation control system and Integrity. In a random sample of prostate plans, Dr. Fontenot compared average vmat delivery times for each control system and found that the average time with Integrity was 71 seconds per arc and 83 seconds per arc with Desktop Pro 7.01, a speed increase of about 15 percent.
“vmat is a nice option to decrease treatment time,” he continues, “and most of our physicians prefer the Elekta systems’ image quality of cbct over mvct.”
Firmly in control – today and in the future
Mary Bird Perkins Cancer Center’s acquisition of Integrity positions the clinic to meet its current and future needs, Dr. Fontenot concludes.
“As treatment techniques become more sophisti-cated, demands on linac capabilities and perfor-mance also increase,” he says. “Accordingly, radia-tion oncology manufacturers and their users must acquire the tools needed to safely and effectively provide the latest delivery paradigms. We believe that the additional degrees of freedom offered by cvdr and mlc interdigitation present the potential to further improve vmat delivery efficiency and provide added flexibility to accommodate future radiotherapy advances.”
Beyond equipment is the character of the Mary Bird Perkins-Elekta relationship, which has helped sustain the center through its technological evolution.
“We have been very pleased with our relation-ship with Elekta. We meet quarterly to discuss areas of concern with the clinical products we use,” says John Gibbons, ph.d., chief of clinical physics. “Elekta has continued to be responsive to us, and it’s clear that they want to work with us. To us, it was critical to have a partner that would listen to us about issues related to treating our patients here in Southeast Louisiana.” l
BY THE NUMBERS
Mary Bird Perkins F Location: Baton Rouge, LA, USAF Patients treated annually: approx. 2,300F Clinical systems: One Elekta Infinity (comm. Aug.
2009, VMAT Feb. 2010), Three Elekta Synergy® (comm. Jan. 2009), Integrity control system (clinical on Elekta Infinity, Jan. 2011), MOSAIQ Oncology Information System
’’We believe that the additional
degrees of freedom offered by CVDR and MLC interdigitation present the potential to further improve VMAT delivery efficiency.”
12
Elekta Around the World
uw SANTIAGO, CHILE
First Spanish-Speaking Training Facility to be Certified
2011 | Clinica Alemana will be certified as the first Spanish-speaking Elekta customer training facility. The head of the radiation therapy department, Radiation Oncologist Andrew Cordova recently spent two weeks observing the clinical training program at University Medical Center Mannheim, Germany. “This is an important step taken by Elekta in Latin America,” says Antonio Ponce, Vice President, Latin America. “We are excited to launch this new program at Clinica Alemana, where they will provide clinical trainings on IGRT, MOSAIQ, XiO and Monaco.”
uw PALM BEACH, FLORIDA, USA
Elekta Users Share Radiation Safety Findings During Radium Society Meeting
MAY | During the American Radium Society’s Annual Meeting, Elekta hosted a symposium where Johns Hopkins University clinicians, Dr. Stephanie Terezakis and Dr. Eric Ford, spoke about improving patient safety in radiation oncology. They shared their findings on safety in a radiation oncology setting using failure mode and effects analysis to identify bottlenecks with risk levels in an RT department workflow study. “The presentations on systematic safety improvement tools and practical strategies for error-proofing led to a fascinating session on where we are now and future plans for radiation therapy and safety,” says Rajinder Singh Dhada, Vice President, Strategic Partnerships.
uw SUNNYVALE, CALIFORNIA, USA
MOSAIQ Receives HITECH Certification for Meaningful Use
FEBRUARY | MOSAIQ became the first comprehensive OIS to receive complete EMR certification. Complete EMR certifica-tion enables U.S. providers to qualify to demonstrate Stage 1 meaningful use under the HITECH Act. “MOSAIQ is a popular solution in many leading cancer care facilities and puts our customers at the front of the line for incentive funds,” says Todd Powell, Executive Vice President, Elekta Software. “We have worked to make MOSAIQ not only the most comprehen-sive, interoperable and robust solution available, but also equipped it to perform functions that all modern EMRs should have to increase efficiency in patient care.”
uw DENVER, COLORADO, USA
Elekta Funds ThinkFirst Community Kids Helmet Day
APRIL | In an effort to protect children from bicycle-related head injuries, Elekta sponsored Bike Helmet Day at INVESCO Field during AANS. During the event, children were fitted with free helmets by ThinkFirst and AANS neurosurgeons. Denver Broncos quarterback Tim Tebow also made a special appearance. “According to AANS, there are about 600 bicycling deaths a year, with two-thirds attributed to traumatic brain injury,” says Veronica Byfield-Sköld, Director of Strategic Marketing, Neuroscience. “Elekta’s brain mapping technology, Elekta Neuromag, helps clinicians diagnose TBI by providing real-time mapping of brain activity.”
uw OTTAWA, ONTARIO, CANADA
Canadian Association of Radiation Oncology and Elekta Award 2011 Research Fellowship
APRIL | The 2011 CARO-Elekta Research Fellowship was awarded to Jeffrey Q. Cao, HBSc, MD, MBA. “As Elekta continues to advance the technological frontiers of cancer management, we always keep in mind that we’re a human care company, and that patients and their families and caregivers drive our innovation,” says Gerry Hogue, Vice President & General Manager, Canada. “Supporting research in this field is consistent with Elekta’s mission. Therefore, we are proud to fund CARO’s radiation oncology research fellowship.”
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uw STOCKHOLM, SWEDEN
Laurent Leksell Awarded the Enterprise Medal of Outstanding Entrepreneurship
APRIL | During an ceremony at the House of Nobility in Stockholm, Elekta’s Executive Director, member of the Board and former President and CEO, Laurent Leksell, received Sweden’s Royal Patriotic Society Business Medal for his outstanding entrepreneurship and contributions to Swedish society. “I am very honored and proud to receive this Medal, and to be part of the group that the Society has honored for what they have contributed to Sweden,” says Leksell.
uw CRAWLEY, UNITED KINGDOM
Elekta and ScandiDos Sign Distributor Agreement
MAY | ScandiDos AB and Elekta entered into a non-exclusive global agreement to distribute ScandiDos’s Delta4PT quality assurance tool. Delta4PT can be used with IMRT and VMAT techniques to provide complete pre-treatment QA that ensures that the dose prescribed in treatment plans is delivered accurately and safely to patients. “As an open source, vendor neutral company, our partnership with ScandiDos ensures that our customers can select QA solutions that best meet their needs and clinical resources,” says Brett North, Marketing Director, Oncology.
uw VILLIGEN, SWITZERLAND
Paul Scherrer Institute and Elekta Collaborate in Proton Therapy Development
MARCH | The Paul Scherrer Institute and Elekta are collaborating to further develop treatment planning and oncology information systems for proton therapy. “Radiation therapy is evolving rapidly in many areas, thanks in large part to innovations in intensity modulation, image guidance and workflow enhancing information management systems over the last decade,” says Stewart Pegrum, Director Particle Therapy. “Our collaboration with PSI focuses on combining technological advances in conventional radiation therapy and proton therapy to create the best possible therapeutic solution.”
uw WUHAN, HUBEI, CHINA
Elekta Helps Organize Opening Ceremony and Training Course in Southern China
MAY | More than 200 persons gathered for an open house and IGRT-VMAT forum at the Hubei Cancer Hospital in Wuhan, China. With more than 350 employees and Elekta offices in Shanghai and Beijing, the company’s presence has grown exponentially throughout China. “Elekta has truly evolved into a comprehensive solutions partner in China,” says Ian Alexander, Executive Vice President, Asia Pacific Region. “We are dedicated to support the rapid growth in demand, not only in equipment, but also in clinical implementation and training services to improve access to high quality cancer treatment and management in the region.”
uw LUDHIANA, INDIA
Christian Medical College & Hospital Upgrades Elekta Compact with MLCi2
JULY | Completing the transformation in less than a week, Christian Medical College & Hospital was the first site to field-upgrade their Elekta Compact® to an MLCi2-equipped Compact. “The speed with which we can integrate MLCi2 demonstrates not only the skill of our installation teams, but also the inherent modularity of MLCi2, such as the way the head itself is fitted and the installation of computer cabinets,” says Russ Cox, Senior Product Manager. “Elekta is committed to further reducing field upgrade times to make it even more seamless, enabling our customers to return to treating patients as quickly as possible.”
uw MOSCOW, RUSSIA
Inaugural Eastern European Users Meeting
JUNE | Hosted in conjunction with Elekta’s Russian distributors, MSM Medimpex, was the first Eastern European Users Meeting. “With more than 80 customers from over 40 different centers, Eastern European clinicians from Russia, Belarus and the Ukraine attended the two-day event,” says Matt Vigar, Product Sales Support Specialist. “The program also featured presentations from Russian-speaking guests from Austria, Estonia and Israel, highlighting the importance of exchanging experience across borders.”
uw SYDNEY, NEW SOUTH WALES, AUSTRALIA
Australasian Users Meeting
SEPTEMBER | Elekta, in collaboration with CMS Alphatech and customer Genesis Care, will host its second Australasian Users Meeting at the Shangri-la Hotel Sydney. Featuring a relaxed and interesting program, the event includes a combination of educational and product-specific presenta-tions from local and international speakers. “Speakers will present on topics such as advanced treatment methodolo-gies, adaptive and enhanced planning tools and RO-specific Oncology Information Systems,” says Melissa Carson, Australasian Sales Manager. “Presenters also plan to share their experiences and best practice methods utilizing Elekta’s cancer care solutions and complete product portfolio.”
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Three Tiers of Safety
Calendar of Events
SEPTEMBER 9-11
2011 Australasian Elekta User Meeting
Sydney, Australia Elekta and CMS Alphatech, in collaboration with the new Genesis Cancer Care Centre at Macquarie University Hospital www.elekta.com.au
SEPTEMBER 11-14
CAP, College of American Pathologists
Dallas, Texas, USA www.cap.org
SEPTEMBER 11-15
ESTRO course, Radiotherapy with Protons and Ions
Paris, France www.estro-education.org/ courses/Pages/Paris2011.aspx
SEPTEMBER 30
Medical Oncology Summit
Eden Roc Renaissance Hotel Miami Beach, Florida, USA www.elekta.com/usersmeeting
OCTOBER 1
Elekta Oncology Users Meeting
Eden Roc Renaissance Hotel Miami Beach, Florida, USA www.elekta.com/usersmeeting
Elekta Charity Bash
Ice Palace, Miami, Florida, USA
OCTOBER 1-6
CNS, Congress of Neurological Surgeons
Washington, DC, USA www.cns.org
OCTOBER 2-6
ASTRO, American Society for Radiation Oncology
Miami, Florida, USA www.astro.org
OCTOBER 2-4
ASRT, American Society of Radiologic Technologists
Miami, Florida, USA www.asrt.org
OCTOBER 2-5
SROA, Society for Radiation Oncology Administrators
Miami, Florida, USA www.sroa.org
OCTOBER 9-14
EANS 2011, 14th European Congress of Neurosurgery
Rome, Italy http://www2.kenes.com/ eans/Pages/Home.aspx
NOVEMBER 4-5
ASCO HIT/EHR Symposium
Atlanta, Georgia, USA www.asco.org
NOVEMBER 16-19
AMPICON, 32nd Annual Conference of the Association of Medical Physicists of India
Vellore, India www.ampicon2011.org.in
NOVEMBER 18-21
Mexican Congress International
Monterrey, Mexico
NOVEMBER 25-27
European Gamma Knife Society
Lausanne, Switzerland www.egks2011.com
NOVEMBER 24-25
AROICON, 33rd National Annual Conference of Association of Radiation Oncologists of India
Jaipur, India www.aroiconjaipur2011.com
DECEMBER 2-6
AES, 65th American Epilepsy Society Annual Meeting
Baltimore, MD, USA
MARCH 25-29, 2012
The 16th International Meeting of the Leksell Gamma Knife® Society
Sydney, Australia www.lgks2012.com
Here are some of the most important events for Elekta customers during the rest of 2011:
Integrity forms the foundation of advanced radiation therapy.
Built on 25 years of experience, Integrity™ is Elekta’s 6th generation digital control system that brings proven reliability,
giving the confidence to safely deliver radiation treatment. Integrity ensures the dose rate is not just prescribed but is actively managed to complete the treatment flawlessly. By support-ing a wide variety of techniques from conformal, through imrt to vmat for conventional and stereotactic applications, it enables clinicians to prescribe treatment techniques best suited to individual patients. l
Confidence through intelligent behaviorIntegrity employs three tiers of safety for absolute confidence in the delivery of radiation dose.
First Tier
1 The prescription is verified when it is received from an external R&V system like Elekta’s MOSAIQ®. Integrity is an intelligent control system, checking that all linear accelerator parameters are deliverable and that they are set correctly
according to the prescription. This smart control system will reject untreatable plans before the patient is on the table or a QA procedure starts.
Second Tier
2 To keep prescription on track and precise, the MLC leaf positions are checked and controlled every 40 milliseconds, while the dose is checked every 20 milliseconds with real-time adjustments being made. Both of these
tiers are overseen by a third tier known as Guardian.
Third Tier
3 Guardian oversees the whole process, supervising and checking that all systems are operating correctly. It does this by constantly monitoring and verifying parameters throughout the treatment, including MLC and
gantry settings. If a discrepancy occurs, Guardian will interrupt treatment. No other linear accelerator control system offers these layered, fail-safe technologies.
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The Future of Radiation Medicine Symposium convened February 17, 2011 in Phoenix, az and brought notable experts in the field of
radiation medicine to present information on the latest advancements in the treatment of spine, brain, lung, liver, breast and prostate cancers, as well as safety considerations in the clinical setting. The symposium was tremendously well attended and well-received, and yielded Elekta’s first Future of Radiation Medicine Report, which distills the significant points of the speakers’ presentations. The unqualified success of the first symposium has spurred interest in hosting similar events in different venues worldwide. Go to www.elekta.com for notices on upcoming Future of Radiation Medicine symposia.
Symposium highlights
During the cme accredited symposium, leading researchers and clinicians discussed how the field of radiation medicine is rapidly changing.
In the past two decades, significant advances have been made in radiation medicine with the introduction of computers, robotics and imaging systems. These tools help to sculpt radiation therapy to the precise dimen-sions of tumors, thereby increasing accuracy and limiting radiation exposure to surrounding healthy tissues. Nearly two-thirds of all cancer patients will receive radiation therapy during their illness.
“In the future, radiation therapy for cancer will be significantly different than today’s treatments, simply because current outcomes are unsatisfactory to patients,” predicts Dr. Robert D. Timmerman, professor and vice chair of radiation oncology at the University of Texas Southwestern Medical Center. “Patients expect that we are actively changing to improve radiation therapy treatment.”
For example, Dr. Timmerman foresees that conventional radiation therapy, which requires six to eight weeks of daily treatments at much lower doses, will largely be replaced by hypofractionated radiation therapy, which delivers very potent, focused beams of radiation to tumors in five or fewer outpatient sessions of less than 30-60 minutes each. Hypo-fractionated radiation therapy might also offer a new way to improve survival in properly selected patients with emphysema by selec-tively causing scarring, or fibrosis, that allows more efficient breathing.
Dr. Dheerendra Prasad, director and associate professor of radiation and neurosurgery at Roswell Park Cancer Institute, says the increased desire of patients to enhance quality of life during brain cancer therapy will lead to widespread use of hypofractionated radiation to specifically target brain tumors – rather than irradiat-ing the entire brain – to save normal brain tissue and preserve brain functions such as memory and fine motor control.
With these same advances in targeted radiation therapy, some radiation oncologists are beginning to deliver the entire course of radiation at the time of breast cancer surgery, which is the most efficient delivery of care. l
!
Download the report at
elekta.com/future
Available in English, Chinese, Japanese and Portuguese.
Future of Radiation Medicine
MORE PRESENTERS AT THE MEETING
F Brian Kavanagh, M.D., M.P.H., Professor of Radiation Oncology, University of Colorado. Topic: Novel Radiobiology, New Clinical Opportunities in SBRT
F Di Yan, D.Sc., Director of Clinical Physics, William Beaumont Hospital. Topic: The Future of Adaptive Therapy
F Eric Ford, Ph.D., Johns Hopkins University. Topic: Radiation Safety: Identifying and Improving Points of Potential Failure
F Peter C. Gerszten, M.D., M.P.H., FACS, Departments of Neurological Surgery and Radiation Oncology University of Pittsburgh Medical Center. Topic: Spine Radiosurgery: Today and Tomorrow
F Joseph P. Imperato, M.D., FACR, Assistant Professor of Clinical Radiation Oncology Northwestern Lake Forest Hospital. Topic: Lumpectomy Cavities: Advanced Visualization and Targeting in RT
Elekta’s successful “Future of Radiation Medicine” Symposium sets the stage for future meetings. Featured was an Elekta “think tank” of clinical radiation oncology user-experts.
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T he purpose of this section is to provide a summary of select papers published in the last quarter in peer-reviewed professional
journals.* I receive a lot of medical journals – far too many to read cover to cover. Most of them are, of course, cancer or neurological disease related, but because my wife also is a physician, a few focus on topics in general internal medicine related topics.
Scanning these helps me highlight not only what I think are emerging trends in our profession,
but also provides me with a sense of what other specialists think are important in our sector.
This quarter, there have been a number I’ve found particularly interesting. I hope they can provide useful snapshots of some of the efforts made by our colleagues to improve clinical care by leveraging Elekta technology, and of some of the trends in medicine that will be driving tech-nological innovations inside our company. l
Joel Goldwein, m.d.
ClinicalViewJoel Goldwein scans the trends of our field
Motion compensation
From the Green Journal (Guckenberger -1), Dr. Guckenberger has reported on a compara-tive planning analysis of four motion compensa-tion strategies: 1. internal target volume concept (ITV); 2. a mean target position (MTP) concept using safety margins adapted based on 4D dose accumulation; 3. gated beam delivery without applying margins for motion compensation; and 4. an approach that combined gating and the MTP concept.
His analysis demonstrated that for targets with large amplitudes (>10-15 mm, avg. 19 mm), the combined gating/MTP concept using 75-87.5 percent duty cycles allowed for the use of a small margin, resulted in small mean lung doses relative to other strategies, and limited the residual target motion effectively to about 10 mm, a residual motion that was compensated for by the use of the small safety margins with the isocenter at the time weighted mean target position.
Microscopic disease
Two other Guckenberger publications from the Red Journal are significant. In one analysis (Guckenberger-2), Guckenberger et. al. performed a retrospective planning study to evaluate doses to microscopic disease (MD) in adaptive radiotherapy (ART) for locally advanced non–small-cell lung cancer (NSCLC) and to model tumor control probability (TCP).
They found that not only did adaptation of radiotherapy to the shrinking GTV (simulat-ing a volume of microscopic disease shrinking synchronously with the GTV or stationary microscopic disease despite shrinkage of the adjacent GTV) not compromise dose coverage of suspect MD, but it also had the potential to increase TCP by >40% compared with radiotherapy planning without ART.
Adaptive radiotherapy
In the March 1 edition of the Red Journal, Guckenberger et. al. published another planning analysis of a small group of patients mostly receiving chemo-radiotherapy for advanced stage NSCLC, in an effort to evaluate the lung sparing and dose escalation potential of adaptive radiotherapy (ART) [Guckenberger-3].
Weekly CT images were acquired for the patients, and deformable image registration was used to calculate accumulated doses over a series of field size adaptations to tumor shrinking. These 4D plans were compared to a 3D conformal treatment plan. Not surprisingly, ART resulted in significantly decreased lung doses without compromising GTV, along with a significant lung GTV-dose escalation.
Implications of the findings from these two papers may be significant for NSCLC where dose escalation studies have been shown to increase tumor control. Additionally, they provide further support for the use of ART in patients receiving combined modality treatment (CMT).
Together, these findings could extend beyond lung cancer itself to other tumor sites where higher doses and lower tumor volumes often are associated with improved outcomes, and where the use of CMT frequently is the rule.
Matthias Guckenberger, from University of Würzburg in Germany, published a number of interesting and interrelated studies, all of which touch on technological developments from Elekta.
*This summary is for general interest only. Elekta takes no responsibility for the clinical data presented in the highlighted papers.
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Bundled payment approach
On a slightly different note, it is always interesting to see what is going on from a patient care perspective world-wide, especially with the emergence of management models such as Accountable Care Organizations (ACO’s) in the United States.
In the United States, ACO’s are among the proposed responses to the enormous pressures being placed on its health care systems, and incorporate a model for risk management, payment reform, and quality enforcement that are supported through a wide range of providers, and one or more hospitals, and have as their goals quality improvement and cost containment.
In the March 17 issue of the New England Journal of Medicine, the Struijs et. al. reported on the experience of the Netherlands’ bundled payment approach for integrated chronic care. That country’s administrative model, while somewhat different from that of ACOs, had very similar aims. As such, the lessons learned may be extrapolated to models upon which Elekta technologies will touch.
For example, most likely because care groups were fully responsible for organizational arrangements necessary to manage their patients, they found that coordination among care providers improved as did protocol compliance and dependence on Electronic Medical Records (think MOSAIQ). They observed that information technology capabilities would need to be further enhanced to support the information needs of their organization, and together these finding suggest to us that our EMR program will have an ever increasing role in new provider paradigms worldwide.
Cancer care delivery in the United States
Associated with this is a review paper published in the April 15 issue of Cancer by Albright et. al., who have provided an excellent summary of the implications of the 2010 Patient Protection and Affordable Care Act on cancer care delivery in the United States.
The authors make the strong case for scrutinizing comparative effectiveness research related activities, as these may eventually impact therapeutic decisions, and affect reimbursement of therapies used “off-label”.
Also envisioned are care delivery models that lead to improved coordination of care and efficiency of healthcare services, and that align evidence-based guidelines with payment incentives.
Payment models will be evaluated looking at the potential, for example, of bundled payments by episode of care versus fee-for-service. These – along with initiatives to incent, measure and report quality, provisions for patients treated on clinical trials and the emergence of ACO models – are all among forces driving increased coordination of care vis-à-vis electronic medical record systems.
Better biological discriminators
In the same issue of Cancer appears a series of articles written by the Interdisciplinary Melanoma Cooperative Group, the German Cancer Society, and the Melanoma Medical Oncology Department of M. D. Anderson Cancer Center.
Collectively, these articles examine factors related to the propensity to develop brain metastases along with factors that portend outcome. An editorial in the issue by Othus et. al. makes the case for incorporating “...better biological discriminators, based on careful clinic-laboratory correlational observa-tions...” into any retrospectively collected data so that more useful prognostic subsets can be defined. This argument is completely consistent with Elekta’s drive to develop and incorporate comprehensive disease registries into their solutions, and as back-ends to our customers’ systems.
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Extending follow-up
Along those lines, a report in Neurosurgery by Gopolan et. al. looked at long term outcomes of patients treated for recurrent and residual nonfunctioning pituitary adenomas with Gamma Knife® radiosurgery.
Compared to previous reports with shorter follow-up, they demonstrated overall tumor control rates at 4 years of 83 percent, with new hormone deficiencies in approximately 40 percent of patients.
As we integrate our Gamma Knife systems into the work flow and department EMR (MOSAIQ), collecting, analyzing and reporting such data will become an integral process in improving patient care
Safety
Of course, safety has received a great deal of recent attention in the RO literature. Of particular note is an editorial by Larry Marks et. al. published in the April 1 issue of the IJROBP. The authors highlight some of the recent activity on the part of our profession, and foresee changes in many facets of practice in the name of safety.
They strongly support the engagement of human factors engineers in the design of graphical user interfaces, a position we staunchly advocate, and one that we extend well beyond our software.
Among many other safety-related recommendations are ones that promote systematic efforts to assess existing processes – in depth, systematic and end-to-end reviews of departmental processes, and participation in registry programs that broadly aggregate radiation incident data. Perhaps most important is their statement that “This cannot be done alone; it needs to be a team initiative.”
Spinal metastases
Of interest, in the March 15 issue of the IJROBP, ASTRO published its guidelines for palliative radiotherapy of bone metastases online (Lutz). Notable in these guidelines is the statement “Stereotactic body radiation therapy can be considered for patients with a newly discovered or recurrent tumor in the spinal column or paraspinal areas; however, it is suggested that stereotactic treatment be reserved for patients who meet specific criteria, who are treated at centers with sufficient training and experience, and who are part of a therapeutic trial.”
The use of stereotactic body radiotherapy holds theoretical promise in the treatment of new or recurrent spine lesions, although the Task Force recommended that its use be limited to highly selected patients and preferably within a prospective trial. “Further, while numerous fractionation schemes have been shown to be effective,” the Task Force felt that no additional trials were necessary to demonstrate the utility of single fraction RT (8 Gy x 1) for painful uncomplicated bone metastases.
Ostensibly, this guideline paves the way for further study of the use of SBRT on spinal metastases.
Albright HW, Moreno M, Feeley TW, Walters R, Samuels M, Pereira A, Burke TW. The implications of the 2010 patient protection and affordable care act and the health care and education reconciliation act on cancer care deliv-ery. Cancer. 2011 Apr 15;117(8):1564-74. doi: 10.1002/cncr.25725
Gopalan R, Schlesinger D, Vance ML, Er EL, Sheehan J. Long-term outcomes Following Gamma Knife Radiosurgery For Patients with a Nonfunctioning Pituitary Adenoma. Neurosurgery. 2011 Apr 14
Guckenberger-1: Matthias Guckenberger, Anthony Kavanagh, Steve Webb, Michael Brada. A novel respiratory motion compensa-tion strategy combining gated beam delivery and mean target position concept – A compromise between small safety margins and long duty cycles. Radiotherapy and Oncology 98 (2011) 317–322.
Guckenberger-2: Matthias Guckenberger, Anne Richter, Juergen Wilbert, Michael Flentje, Mike Partridge. Adaptive Radiotherapy
for Locally Advanced Non–Small-Cell Lung Cancer Does Not Underdose the Microscopic Disease and has the Potential to Increase Tumor Control. International journal of radiation oncology, biology, phys-ics 18 April 2011 18 April 2011 10.1016/j.ijrobp.2011.01.067)
Guckenberger-3: Matthias Guckenberger, Juergen Wilbert, Anne Richter, Kurt Baier, Michael Flentje Potential of Adaptive Radiotherapy to Escalate the Radiation Dose in Combined Radiochemotherapy for
Locally Advanced Non–Small Cell Lung Cancer. International journal of radia-tion oncology, biology, physics 1 March 2011 (volume 79 issue 3 Pages 901-908 DOI: 10.1016/j.ijrobp.2010.04.050)
Stephen Lutz, Lawrence Berk, Eric Chang, Edward Chow, Carol Hahn, Peter Hoskin, David Howell, Andre Konski, Lisa Kachnic, Simon Lo, Arjun Sahgal, Larry Silverman, Charles von Gunten, Ehud Mendel, Andrew Vassil, Deborah Watkins Bruner, William Hartsell. Palliative Radiotherapy for Bone Metastases:
An ASTRO Evidence-Based Guideline. International journal of radiation oncology, biology, physics 15 March 2011 (volume 79 issue 4 Pages 965-976 DOI: 10.1016/j.ijrobp.2010.11.026)
Struijs JN, Baan CA. Integrating Care through Bundled Payments – Lessons Learned from the Netherlands. N. Engl J Med 354;11. March 17, 2011. Pages 990-991
ClinicalView
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Nowhere to HideIndian center uses SonoWand Invite to plot course to, and safely remove, brain tumors
Typically, neurosurgeons gain access to and remove brain tumors by consulting pre-oper-ative images, usually those from the patient’s
diagnostic mri. While still a tricky procedure, the sophistication of today’s neurosurgical techniques has made brain tumor resections as safe as they’ve ever been. In recent years, intra-operative imaging and navigational technology have elevated surgi-cal removal of brain tumors to a new level – by fine-tuning guidance to the lesion and facilitat-ing more complete extraction of the pathology.
At Mumbai, India’s actrec (The Advanced Centre for Treatment, Research & Education in Cancer), neurosurgeons have employed SonoWand Invite™ in 15 patients with brain tumors since the center acquired the system in July. The integration of sophisticated intra-operative 3d ultrasound and navigation technology in SonoWand provides both the optimal path to the tumor and – with 3d ultrasound – ongoing images of the operative site, enabling the surgeon to safely remove all visible traces of the tumor.
Surgeons gain new vision inside brain
“The goal in any tumor resection is to extract the tumor – and to extract it completely – without harm-ing healthy brain tissue, which is quite a challenge,” says Aliasgar V Moiyadi, mch., Assoc. Professor and Consultant Neurosurgeon at actrec, part of Mumbai’s Tata Memorial Centre. “SonoWand helps you see what you’re removing, how much you’ve removed and how much more you could resect than what’s visible by using your eyes or intra-operative microscope.”
SonoWand Invite combines a high-performance ultrasound scanner with a built-in navigational computer and optical tracking system. The system supports several trackable instruments and accesso-ries, such as navigators and ultrasound probes. Planning and navigation displays enable all multi-planar views, in addition to a unique, user-friendly “anyplane view,” which displays the imaging information in the plane of the surgical trajectory.
Aiding “search and destroy” against tumors
Diagnostic mri images with surface fiducial marks are imported into SonoWand and clinicians register the fiducial marks on both the images and – with an optically-tracked probe – the fiducial marks on the patient’s scalp. All points in the patient’s cranium will have their own Cartesian coordinates, which corre-spond to the same point in the image. This is how navigation helps plan the entry point into the brain.
The entry point indicates where the surgeon places the craniotomy. By using the navigational capability of the system, the surgeon can customize
the craniotomy to just the right size. This avoids unnecessarily large or misplaced craniotomies. Once the craniotomy is performed and the dura mater is opened, however, leakage of cerebral spinal fluid causes the brain to shift.
“The pre-operative images will now be useless because the anatomy has changed,” Dr. Moiyadi explains. “At that point, we turn to the ultrasound capabilities of SonoWand, which provides a probe that takes a sector view of multiple 2d images and fuses them to afford a 3d volume. That 3d volume now serves as your new navigational image. The best part is that the ultrasound probe is already navigating with the SonoWand computer via optical tracking and navigational spheres, so we know exactly which part of the brain the probe is imaging.”
Sophisticated ultrasound guides tumor removal
Following the pre-determined path to the tumor, the surgeon can begin to debulk the lesion. As debulking progresses, the brain can shift again, necessitating image updates.
“Ultrasound allows us to update that information repeatedly without taking too much time,” he says. “Also, it’s important to note that SonoWand dedicated cranial ultrasound provides image quality that is far superior to that of any conventional ultrasound system.”
Exceptional pre-operative navigational capabilities and high-quality, navigated ultrasound have clearly benefited patients at actrec, helping ensure safer access to brain tumors and more complete removal via real-time imaging, Dr. Moiyadi observes. l
SonoWand Invite is a compact, single-rack system that revolutionizes intra-operative ultrasound by providing integrated, high-precision 3D-imaging - on demand.
SBRT for medically inoperable early stage lung cancer a key topic for presenters
During the 14th World Conference on Lung Cancer held in Amsterdam in June, leading users of Elekta Stereotactic Body Radiation
Therapy (sbrt) technology presented their findings on the use of sbrt to treat early stage, non-small cell lung cancer (nsclc) patients who had operable disease but elected to be treated with sbrt. The analysis demonstrated that sbrt had overall survival and cancer-specific outcomes similar to reported surgical series. This suggests that it might be possible, in the future, for select patients who would be considered operative candidates to be able to choose between a thoracotomy or sbrt as their primary treatment.
In an oral presentation, Dr. Andrew J. Hope, Radiation Oncologist, Princess Margaret Hospital (Toronto, Canada) discussed the experience of a multinational consortium of Elekta collaborators that has treated operable, early stage lung cancer. Titled, Outcomes of operable patients with nsclc treated with image guided stereotactic body radiation therapy (ig-sbrt), the consortium found that the 505 tumors in the 483 operable patients declining a thoracotomy and subsequently treated with ig-sbrt had overall survival and cancer-specific outcomes similar to reported surgical series. With the condition that additional follow-up would be required, the data support continued investigation of ig-sbrt, suggesting that ig-sbrt is potentially an equivalent alternative to surgery in operable patients with early stage lung cancer.
According to Dr. Hope, this finding supports ongoing clinical trials that are comparing non-invasive radiation treatments, such as ig-sbrt, with surgery. “It may be that someday, patients could choose between a thoracotomy or a completely non-invasive approach to cure early stage lung cancer.”*
Dr. Hope is a member of the Elekta Lung Research Group (elrg), an international collaboration of physicians and physicists that is evaluating clinical outcomes in early stage nsclc patients. To date, they have accumulated data on more than 500 such patients and identified medical and technical factors that affect tumor control and toxicity. Their collective experience is among the largest multinational series of patients treated with ig-sbrt to date. l
Asian nasopharyngeal cancer research group formed in Singapore
In early March, the inaugural meeting of Elekta’s newly-formed trans-Asia consortia met in Singapore to focus on the study of nasopharyngeal
carcinoma (npc). According to the World Health Organization, npc incidence rates are less than one per 100,000 in most populations, except among inhabitants of southern China, where an annual incidence of more than 20 cases per 100,000 is reported.
“Group members universally expressed great interest in participating in the collaborative, and there was overwhelming enthusiasm for the initiative,” says Joel W. Goldwein, m.d., Elekta’s Sr. Vice President of Medical Affairs. “The group elected Associate Prof. Jay Lu, Head of Radiation Oncology, National University Hospital, Singapore, to serve as consortia chairman, reviewed their respective experiences in treating npc and deliberated research topics.”
During the meeting, a significant revelation was that the total number of patients seen across the collective centers was estimated to be in the thou-sands. In contrast, the largest series reported in the medical literature is less than 500 patients, often collected over many years, suggesting great potential for the research program.
William Beaumont Hospital (Royal Oak, Michigan, usa) clinicians Dr. Di Yan, Director and Clinical Professor of Physics Radiation Oncology, and Dr. Alvaro Martinez, Chairman of Radiation Oncology, who, along with Elekta’s Asian Business Unit, helped coordinate and conduct the meeting. l
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An Enormous Research PotentialElekta’s Clinical Consortia Program is a venue for fostering collaboration with key opinion leaders in cancer care to improve patient outcomes and advance technology. Here are some groups that, in partnership with Elekta, continue to push clinical boundaries.
FOCUS ON: CLINICAL COLLABORATION
References* ACOSOG Z4099/RTOG 1021: Phase III Study of Sublobar Resection versus Stereotactic Body Radiation Therapy in High Risk Patients with Stage I Non-Small Cell Lung Cancer (NSCLC) Radiotherapy Form
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E lekta users from Europe, Asia, the Middle East, North America and Africa converged on Hotel Hohe Düne in Warnemünde,
Germany June 16-19 to participate in Elekta’s fifth European Users’ Conference.
Approximately 390 clinicians and scientists attended 31 presentations and workshops given by Elekta users and company representatives on a wide range of cancer management topics. The Users’ Conference was preceded by the Elekta Stereotactic Users’ Meeting, June 15-16.
“The European Users’ Conference has evolved to become an established, respected platform on which the forefront of modern radiation therapy is dis-cussed,” says Olof Sandén, Executive Vice President, Europe and aflame. “This meeting continues to attract the most technologically and clinically sophisticated physicians and scientists in this region of the world to share their experience and knowledge.”
Hospital in Turin excels with Axesse and Clarity
Umberto Ricardi, m.d., radiation oncologist at the University Hospital of Turin was among several invited speakers. Dr. Ricardi discussed Turin’s nine months of clinical experience with Elekta Axesse™ as a dedicated system for stereotactic radiation therapy and radiosurgery of body and brain tumors, and lately, spine tumors as well.
“We have treated 190 patients for a total of 210 lesions,” he says. “The system is quite good, we really appreciate it. The Hexapod™ table is indispensable for precise fine-tuning of the patient’s position, which is particularly important for stereotactic therapy using ablative doses. In addition, the iGuide® system provides accurate localization of the patient in both body and brain tumor cases. We also appreciate the ability to finely shape treatment fields with Beam Modulator™.”
Two months ago, the University Hospital of Turin began using Elekta Axesse for sbrt of spine tumors, and has completed six cases.
Dr. Ricardi also gave a presentation on soft tissue igrt, specifically the use of Clarity™ soft tissue visualization for patients with prostate cancer. “We are using it for patients who are candidates to receive ‘radical’ treatments [i.e., radiation only] as a guide for hypofractionated radiation therapy,” he says.
At University Hospital, Clarity has evolved to be an ideal solution to add an imaging component to the workflow of its Precise Treatment System, which is not equipped with an integrated kV imaging system.
“It really was a cost-effective solution that required absolutely no modification of the linac,” Dr. Ricardi observes. “At the time of ct simulation of patients scheduled for radiation therapy of prostate cancer, we evaluate how well we can visualize the prostate with Clarity ultrasound. If the patient’s prostate gland is well visualized and evaluable with Clarity, then he can receive therapy on Precise with daily ultrasound-based igrt. If the prostate is not well seen – bladder filling is not ideal, for example – we can treat these patients with Elekta Synergy® and perform daily cone-beam ct igrt.”
“The prospect of reducing waiting times and still being able to offer igrt for these patients – either cone beam or Clarity – has been very beneficial,” he says.
Elekta Clarity Society formed at Users’ Meeting
“Clarity of Vision” was the theme of a special cocktail event, bringing together European users and customers of Elekta’s Clarity solution. Panelists discussed the promising future of ultrasound in radiotherapy, especially in the area of real-time monitoring. An offshoot of this event will be repeated in Miami later this year, in the first ever meeting of the newly created Clarity Society. l
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has enabled the University Hospital of Turin to reduce the waiting list for patients with prostate cancer.
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Europe Users’ Conference – the top minds in cancer management.
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More attention and resources are flowing into cancer management clinics than ever before, improving cancer survival and the over-
all patient experience. We hear about it from time to time – not only from clinics that are effectively harnessing our technology to help patients, but also from centers that have invested a lot of time, creativity and money into transforming the “can-cer ward” into an environment where optimism lives, a home away from home, a place of hope.
It’s time we recognized and highlighted your efforts. Wavelength is the best place to show your fellow cancer care professionals what you did to make your clinic stand out, and to give them some inspiration about what they can do to make their
clinic a special place for patients – the people who are the focus of everything we do.
Tell us what makes your center unique. Write a brief description of what you did to improve your facilities or services. Photographs (high-resolution jpegs) are welcomed and encouraged if they help tell the story. Include your name, clinic or hospital name and email address and send to [email protected].
We look forward to hearing from you! Remember (and we’re pretty sure this translates internationally): “The early bird gets the worm!” l
Stand Up and Stand Out!
Here are some examples to get you thinking:
F Artwork (especially patient artwork)
F Architecture
F Meditation rooms
F High tech
F Celebrity visits
F Cancer survivor events
F Patient awards
F General patient comfort
F Waiting room
F Support groups
Your challenge: Tell us why we should feature your clinic in the February 2012 issue of Wavelength. E-mail your story to [email protected]
Advanced therapies made easier
Experience the Elekta Difference
Radiotherapy techniques are becoming increasingly sophisticated, requiring more time treatment verification, and delivery, Elekta gives you greater confidence to define and raise the standard of human care. Visit us at elekta.com/experience.
Managing complexityso you can focus on what matters
