Tomotherapy

Tomotherapy Hi Art

Tomotherapy or helical tomotherapy (HT) is a type of radiation therapy in which the radiation is delivered slice-by-slice (hence the use of the Greek prefix tomo-, which means "slice"). HT is a form of computed tomography (CT) guided intensity modulated radiation therapy (IMRT). HT machines are purpose built for IMRT and differ from IMRT delivered by conventional medical linear accelerators (LINACs) in a number of ways. The main difference is that in HT a narrow intensity modulated pencil beam is delivered from a rotating gantry while the patient is simultaneously moved through the bore, compared to the much wider intensity modulated beam and static patient in conventional IMRT.[1] HT units are therefore better able to target treatment sites throughout the body without a pause for the patient to be moved and set-up differently.[2][3]

History

The tomotherapy technique was developed in the early 1990s at the University of Wisconsin–Madison by Professor Thomas Rockwell Mackie and Paul Reckwerdt.[4] A small megavoltage x-ray source was mounted in a similar fashion to a CT x-ray source, and the geometry provided the opportunity to provide CT images of the body in the treatment setup position. Although original plans were to include kilovoltage CT imaging, current models use megavoltage energies. With this combination, the unit was one of the first devices capable of providing modern image-guided radiation therapy (IGRT).[5]

The first implementation of tomotherapy was the Corvus system developed by Nomos Corporation, with the first patient treated in April, 1994.[6][7] This was the first commercial system for planning and delivering intensity modulated radiation therapy (IMRT). The original system, designed solely for use in the brain, incorporated a rigid skull-based fixation system to prevent patient motion between the delivery of each slice of radiation. But some users [8] eschewed the fixation system and applied the technique to tumors in many different parts of the body.

General principles

In general, radiation therapy (or radiotherapy) has developed with a strong reliance on homogeneity of dose throughout the tumor. Tomotherapy embodies the sequential delivery of radiation to different parts of the tumor which raises two important issues. First, this method is known as "field matching" and brings with it the possibility of a less-than-perfect match between two adjacent fields with a resultant hot and/or cold spot within the tumor. The second issue is that if the patient or tumor moves during this sequential delivery, then again, a hot or cold spot will result. The first problem is reduced by use of a helical motion, as in spiral computed tomography.[5] The second requires close attention to the position of the target throughout treatment delivery.

At this time, the Hi-Art system manufactured by TomoTherapy Inc. is the primary tomotherapy device in use although there are still a number of Corvus systems being used. TomoTherapy TomoHD systems are also in use.

Patient undergoing tomotherapy, face and body covered.

TomoTherapy "beam on" times vary compared to normal radiation therapy treatment times (HT irradiation time can be as low as 6.5 minutes for common prostate treatment[9]) but do add an additional 2–3 minutes for a daily CT. The daily CT is used to precisely place the radiation beam and allows the operator to modify the treatment should the patient's anatomy change due to weight loss or tumor shrinkage (image-guided radiation therapy). Lung cancer, head and neck tumors, breast cancer, prostate cancer, stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are some examples of treatments commonly performed using tomotherapy.[10][11][12] Some research has suggested HT provides more conformal treatment plans and decreased acute toxicity.[13]

There are few head to head comparisons of HT and other IMRT techniques, however there is some evidence that VMAT can provide faster treatment while HT is better at sparing surrounding healthy tissue and providing a uniform dose.[14][15][16]

Static beam tomotherapy

TomoTherapy has recently introduced a static mode, branded as topotherapy.[17] The technology enables fixed beam treatments by moving the patient through the machine bore while maintaining specified beam angles.

Non-helical static beam techniques such as IMRT and TomoDirect are well suited to whole breast radiation therapy. These treatment modes avoid the low-dose integral splay and long treatment times associated with helical approaches by confining dose delivery to tangential angles.[18][19] The primary concern of low-dose splay is the potential risk of secondary malignancy, particularly in the contralateral breast.[20] This risk is accentuated in younger patients with early-stage breast cancer, where cure rates are high and life expectancy is substantial.[20] Static beam angle approaches aim to maximise the therapeutic ratio by ensuring that the tumour control probability (TCP) significantly outweighs the associated normal tissue complication probability (NTCP).[21][22][23]

Mobile tomotherapy

Due to their internal shielding and small footprint, TomoTherapy Hi-Art and TomoTherapy TomoHD treatment machines are the only high energy radiotherapy treatment machines used in relocatable radiotherapy treatment suites. Two different types of suites are available: TomoMobile developed by TomoTherapy Inc. which is a moveable truck and Pioneer, developed by UK-based Oncology Systems Limited. The latter was developed to meet the requirements of UK and European transport law requirements and is a contained unit that is placed on a concrete pad, delivering radiotherapy treatments in less than five weeks.[24][25]

See also

References

  1. ↑ Mayles, Philip; Nahum, Alan; Rosenwald, Jean-Claude, eds. (2007). Handbook of radiotherapy physics theory and practice. Boca Raton: CRC Press. p. 969. ISBN 9781420012026.
  2. ↑ Colligan, S J; Mills, J (2012). "Beam therapy equipment". In Sibtain, Amen; Morgan, Andrew; MacDougall, Niall. Radiotherapy in practice : physics for clinical oncology. Oxford: Oxford University Press. doi:10.1093/med/9780199573356.001.0001. ISBN 9780199573356.
  3. ↑ Fenwick, John D.; et al. (October 2006). "Tomotherapy and Other Innovative IMRT Delivery Systems". Seminars in Radiation Oncology. 16 (4): 199–208. doi:10.1016/j.semradonc.2006.04.002. PMID 17010902.
  4. ↑ Holmes, Timothy W.; et al. (June 2008). "Stereotactic Image-Guided Intensity Modulated Radiotherapy Using the HI-ART II Helical Tomotherapy System". Medical Dosimetry. 33 (2): 135–148. doi:10.1016/j.meddos.2008.02.006. PMID 18456165.
  5. 1 2 Mackie, T R (7 July 2006). "History of tomotherapy". Physics in Medicine and Biology. 51 (13): R427–R453. doi:10.1088/0031-9155/51/13/R24. PMID 16790916.
  6. ↑ Mackie, T. Rockwell; et al. (January 1999). "Tomotherapy". Seminars in Radiation Oncology. 9 (1): 108–117. doi:10.1016/S1053-4296(99)80058-7.
  7. ↑ Woo, Shiao Y.; et al. (June 1996). "A comparison of intensity modulated conformal therapy with a conventional external beam stereotactic radiosurgery system for the treatment of single and multiple intracranial lesions". International Journal of Radiation Oncology*Biology*Physics. 35 (3): 593–597. doi:10.1016/S0360-3016(96)80023-X. PMID 8655384.
  8. ↑ Squires M, Hu Y, Byrne M, et al. Static beam tomotherapy as an optimisation method in whole breast radiation therapy (WBRT). J Med Radiat Sci, Forthcoming 2017.
  9. ↑ Piotrowski, T; et al. (June 2014). "Tomotherapy: implications on daily workload and scheduling patients based on three years' institutional experience". Technology in cancer research & treatment. 13 (3): 233–42. doi:10.7785/tcrt.2012.500374. PMID 24066951.
  10. ↑ Woo, Shiao Y.; et al. (June 1996). "A comparison of intensity modulated conformal therapy with a conventional external beam stereotactic radiosurgery system for the treatment of single and multiple intracranial lesions". International Journal of Radiation Oncology*Biology*Physics. 35 (3): 593–597. doi:10.1016/S0360-3016(96)80023-X. PMID 8655384.
  11. ↑ Cherry, Pam; Duxbury, Angela, eds. (2009). Practical radiotherapy : physics and equipment (2nd ed.). Chichester: Wiley-Blackwell. p. 210. ISBN 9781405184267.
  12. ↑ Peñagarícano, José A; et al. (2006). "Dosimetric comparison of Helical Tomotherapy and Gamma Knife Stereotactic Radiosurgery for single brain metastasis". Radiation Oncology. 1 (1): 26. doi:10.1186/1748-717X-1-26. PMC 1557668. PMID 16887031.
  13. ↑ Yu, Mina; et al. (2013). "A comparison of dosimetric parameters between tomotherapy and three-dimensional conformal radiotherapy in rectal cancer". Radiation Oncology. 8 (1): 181. doi:10.1186/1748-717X-8-181. PMC 3721992. PMID 23866263.
  14. ↑ "VMAT vs. Tomotherapy". Imaging Technology News. Retrieved 6 June 2016.
  15. ↑ Rao, M.; et al. (November 2009). "Evaluation of Arc-based Intensity Modulated Radiotherapy for Head and Neck Cancer". International Journal of Radiation Oncology*Biology*Physics. 75 (3): S419. doi:10.1016/j.ijrobp.2009.07.959.
  16. ↑ Oliver, Michael; et al. (15 November 2009). "Comparing planning time, delivery time and plan quality for IMRT, RapidArc and Tomotherapy". Journal of Applied Clinical Medical Physics. 10 (4): 3068. doi:10.1120/jacmp.v10i4.3068. PMID 19918236.
  17. ↑ Gonzalez V, Buchholz D, Langen K, et al. Evaluation of two tomotherapy-based techniques for the delivery of whole-breast intensity-modulated radiation therapy. Int J Radiat Oncol Biol Phys 2006; 65: 284–90.
  18. ↑ Squires M, Hu Y, Byrne M, et al. Static beam tomotherapy as an optimisation method in whole breast radiation therapy (WBRT). J Med Radiat Sci, http://onlinelibrary.wiley.com/doi/10.1002/jmrs.232/abstract
  19. ↑ Goddu SM, Chaudhari S, Mamalui-Hunter M, et al. Helical tomotherapy planning for left-sided breast cancer patients with positive lymph nodes: Comparison to conventional multiport breast technique. Int J Radiat Oncol Biol Phys 2009; 73: 1243–51.
  20. 1 2 Stovall M, Smith SA, Langholz BM, et al. Dose to the contralateral breast from radiotherapy and risk of second primary breast cancer in the WECARE study. Int J Radiat Oncol Biol Phys 2008; 72: 1021–30.
  21. ↑ Franco P, Catuzzo P, Cante D, et al. TomoDirect: An efficient means to deliver radiation at static angles with tomotherapy. Tumori 2011; 97: 498–502.
  22. ↑ Franco P, Ricardi U. Tomo Direct to deliver static angle tomotherapy treatments. J Nucl Med Radiat Ther 2012; 3:5.
  23. ↑ Murai T, Shibamoto Y, Manabe Y, et al. Intensity modulated radiation therapy using ports of Tomotherapy (TomoDirect): Comparison with the TomoHelical mode. J Radiat Oncol 2013; 8: 68.
  24. ↑ "Radiation Therapy on the Road". Imaging Technology News. Retrieved 6 June 2016.
  25. ↑ "OSL launches Pioneer relocatable radiotherapy suite". medicalphysicsweb.org. Retrieved 6 June 2016.
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