1. Efficacy of IMRT through DMLC and inverse planning: A preliminary results James C.Li, Hsiang-Chi Kuo, Chi-Wei Hsu Department of Radiation Oncology, Chung Shan Medical & Dental College Hospital

2. Introduction Before the commencement of the intensity modulation radiation treatment (IMRT) technique in our department, We selected some specific disease sites that were deemed good candidate for IMRT treatment with our dynamic multileaf collimator (DMLC) and Helios inverse planning. Our selection criteria are: ) Target with concavity that need IMRT technique to achieve dose conformity, (e.g. prostate cancer, pharyngeal cancer and NPC) and spare critical target that may lie adjacent to it. ) Disease site in thorax or abdomen surrounded by critical tissue or critical organ that need IMRT technique to achieve a tighter margin and lower the integral dose to spare more critical tissue. The implementation of this technique on these sites should also take the respiratory motion into account. ) Multiple lesions that may be difficult to treat with conventional technique without splitting the treatment field and need IMRT technique to localized treatment dose & produce a more conformal dose distribution.

4. IMRT technique with DMLC Intensity Modulated X-ray image by 40 pairs DMLC Department of Radiation Oncology, Chung Shan Medical & Dental College Hospital Leaf sequence calculated by Cadplan LMC Optimal Fluence generated by inverse planning

6. Patient 1 : Patient Liu XX, a75 year old female patient diagnosed to have frontal lobe malignant lymphoma post resection and whole brain radiotherapy for dose of 30 Gy/17 fractions, she was setup for a final boost to the local tumor bed region. We did a conventional microMLC planning with eight conformal portals to the isocenter of the tumor, and also simulated with an inversely planned radiation treatment. Comparison of the two plans showed quite similar isodose distribution at the tumor region but an advantage in the lesser normal brain exposed to the prescription dose. IMRT SRT

7. SRT, more normal brain accept dose > 90% IMRT

8. Patient 2 : Patient Chang XX, a 62 years old male patient diagnosed to have a malignant olfactory neuroblastoma of the right orbital region with pressing on the eyeball resulting in proptosis and ptosis. He has surgical extirpation of the main tumor mass and post operative radiation therapy. X-knife multiport conformal radiation planning was done and delivered, but we also simulated with our helios inverse planning system to test the advantage of IMRT to said tumor. Above are comparative images of the resulting IMRT plan and the X-knife multiport conformal therapy, no advantage could be seen in the uniformity of the central tumor dose for the IMRT planning as compare to the X-knife conformal treatment, but a tighter dose distribution in the peripheral region for the X-knife treatment makes it slightly advantageous. IMRT

9. SRT spare more left eye and left Len

10. IMRT for NPC recurrence

11. Patient 3 Patient Chien XX, 53 years old male patient diagnosed to have NPC two years prior to consultation, with recurrence at the nasopharynx proper. Conventional multiportal conformal radiation therapy was done, with excellent results, but we also simulated with the Helios inverse planning system to determine if a better dose distribution could be achieved. The results shows a better coverage of the tumor site by the IMRT technique. There is better dose uniformity (89%-104%) as compare to the conventional conformal treatment (86%-125%). Target TM joint Brain stem cord

12. IMRT 6 field Conformal

13. Patient 4 Patient Chien XX, a 40 years old female patient with primary NPC with no visible neck node metastasis was treated by conventional radiation therapy for dose of 60 Gy with very good tumor response, the primary dose was escalated to a total of 76 Gy, with conventional conformal therapy. We also simulated with Helios inverse planning system to do IMRT treatment. Above is the comparison of the conventionally planned conformal treatment and the IMRT inversely planned treatment. Good tumor homogeneity in the tumor to a level of ±<8% was achieved as compare to the conventional treatment which varied widely in the range of ± > 15%. Aside there was also parotid gland sparing in the IMRT plan with a 30% advantage as compare to the conventional conformal radiation therapy plan. PTV, IMRT PTV, 6 field conformal Parotid gland, 6 field conformal Parotid gland, IMRT

14. IMRT Conformal Rectum, conformal Bladder, conformal Rectum, IMRT Bladder, IMRT Patient 5

15. Rectum, conformal Rectum, IMRT Bladder, conformal Bladder, IMRT Patient 6 IMRT 6 way conformal

16. Patient 5 Mr Hsu X, a 73 year old prostate carcinoma patient who has a moderately enlarge prostate gland. Here we shows a conventional conformal treatment given by a 6 fields treatment portal versus an inversely planned IMRT plan using 6 coplanar portals. Results showed the superiority of the latter plan in term of dose uniformity and critical tissues and organs sparring. Patient 6 Mr Hwang XX, a 75 years old patient diagnosed to have a locally advance prostate carcinoma with a moderately enlarge prostatic gland with slight urinary obstruction. He was treated by conventional 6 field conformal radiation therapy to dose of 60 Gy with a relatively large field, with further reduction of the field and escalation to a total dose of 74 Gy. He responded quite well to the above treatment with good tumor control. We made virtual simulation of this patient plan with the Helios inverse planning system with 6 coplanar IMRT field. The resulting dose distribution and dose histograms were compare. It clearly shows the superiority of the IMRT plan to the conventional conformal plan in term of dose uniformity, and critical organ sparing. This would make us more confident in escalating the local tumor dose to increase TCP, and limiting NTCP, especially to the rectum. Femur head, conformal Femur head, IMRT

17. Patient 7 Mr Tsai XX, a 74 years old male patient diagnosed with hypopharyngeal carcinoma with extension to the adjacent structure leading to obstruction of the upper airway needing tracheostomy, we gave him conventional radiation therapy for dose of 60 Gy/34 fraction and further escalation of local dose to 76 Gy via a 3-field conventional conformal radiation therapy. The patient tumor was totally controlled by the above regimen with minimal fibrosis. We did a comparative study of the conventional conformal therapy and the inversely planned IMRT plan, the dose distribution clearly elucidate the superiority of the IMRT plan vis-à-vis the conventional conformal radiation plan in term of tumor dose homogeneity and critical organ and structure sparring e.g. tongue, mandible and spinal cord.

18. Primary target node tongue cord mandible 6 way IMRT

19. IMRT 2 way conventional

20. Patient 8 A plan for the multiple neck nodes metastasis in a buccal carcinoma patient showed that IMRT plan are superior to the conventionally planned conformal radiotherapy in term of tumor dose uniformity and normal structure or organ sparring e.g. mandible, parotid glands and the adjacent tissues.. Parotid rt., IMRT Parotid lt., 2 way conventional Parotid rt., 2 way conventional Parotid lt., IMRT

21. Patient 9 Patient Wei XXX, a 72 year old female patient diagnosed to have advance uterine endometrial carcinoma stage IIB with parametrial lymph node metastasis post initial whole pelvis radiation therapy with dose of 50 Gy, with escalation of the dose to the uterus and adjacent parametium via conventional conformal radiation therapy and was compare to a virtual simulated IMRT plan clearly showing greater dose escalation to the uterine cervical region and adjacent parametrium with less critical organ dose ( which include rectum, bladder, small bowl). These clearly shows the advantage of the IMRT plans .

22. IMRT 4 wayconformal

23. Patient 10 Mr Tsai XX, a 70 years old male lung cancer patient planned by Helios inversely planning system shows a highly concentrated radiation dose to the tumor region as compared to the normal tissues, with bulk of the lung and the heart spared by the IMRT plan. The conventional conformal treatment plan showed similar dose distribution in the main tumor region, but also delivered a much higher dose to the adjacent normal lung tissue and heart. IMRT

24. Lung_left, IMRT Lung_left, conventional Conventional Conformal IMRT