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Introducing Elekta Synergy®
Pantai Hospital Kuala Lumpur recently acquired the Elekta
Synergy® system, a state-of-the-art system for radiation
therapy. With this acquisition, Pantai Hospital Kuala Lumpur
joins the ranks of leading cancer centers around the world
that are able to offer their patients Volumetric (3D) ImageGuided Radiation Therapy.
Revolutionizing cancer care
Radiation therapy is a powerful weapon against cancer.
However, its utilization may come at a heavy price of
damaging healthy tissue, which may lead to debilitating
side effects.
Until recently, technology that truly integrated 3D imaging
with the treatment system was not available. Patients were
first imaged with an imaging device, such as diagnostic
X-Rays or Computed Tomography (CT) Scanner, and then
moved to the radiation therapy machine. This scenario
was associated with accuracy uncertainties brought about
by factors such as anatomical changes from the time of
diagnosis to the point of treatment, internal organ motion
and errors in patient set-up - all of which can potentially
translate in an imprecise, and therefore ineffective,
treatment delivery.
The introduction of the Elekta Synergy® has revolutionized
radiation therapy by allowing 3D / Volumetric imaging
to be truly integrated with the treatment system. It is the
first advanced and fully digital Image-Guided Radiation
Therapy (IGRT) platform that enables clinicians to perform
three-dimensional (3D) imaging on the tumor at the point
of treatment. The use of the Elekta Synergy® provides
clinicians the unprecedented ability and confidence to
pursue the treatment of tumors more aggressively whilst
minimizing the damage to the surrounding healthy tissue.
Enabling Image-Guided Radiation Therapy
The Elekta Synergy® provides imaging in 3D taken at the
time of treatment, an approach called the IGRT solution.
Elekta’s X-Ray Volume Imaging (XVI) Cone-Beam
technology enables hi-contrast and detailed visualization of
soft tissue information for any area of the body and at the
time of treatment. The XVI software analyzes the 3D-Image
taken at the time of treatment and registers it against the
image taken during simulation to acquire spatial inaccuracy
data in all positional dimensions. Based on these inaccuracy
data, the system then automatically repositions the patient
to the correct point. Treatment delivery can now commence
with full confidence.
As a result of this clinical confidence, side effects are
dramatically minimized by effectively reducing margins
previously set to account for anatomical uncertainties for
target (tumor) dimensions, location and movement. In
addition, because clinicians are now sure that they “see
what they treat”, doses to the tumor can be increased and
sparing of healthy tissue is dramatically improved. Patients
can be treated more effectively and in a much shorter period
of time.
Simply put, 3D IGRT with the Elekta Synergy® results in
higher quality treatments which, more importantly, translates
into improved patient outcomes.
Enabling Intensity Modulated Radiation
Therapy
The advantages offered by the Elekta Synergy® perfectly
complement and increases the effectiveness of modern
treatment modalities such as Intensity Modulated Radiation
Therapy (IMRT). IMRT is an advanced treatment modality
that allows radiation beams to be delivered in multiple
beamlets or segments of varying intensity, accumulating
into a dose that matches the 3D shape of the tumor target.
The high-conformity of the radiation dose to the tumor
allows the radiation beams to cover the target and avoid
surrounding healthy tissue much more effectively.
However, the challenge in IMRT has been to accurately
direct the radiation dose towards the target. A target that
may significantly move or shift from the time of planning to
the point of treatment and also between or during treatment
sessions (inter- and / or intra-fractionally).
By utilizing 3D imaging with the Elekta Synergy® at the
point of treatment, clinicians are able to accurately guide
the radiation doses to its supposed target, thus inspiring
confidence for truly effective IMRT delivery.
Clinicians can further take full advantage of IMRT
delivery without the need of invasively implanting target
surrogate markers to account for & limit inaccuracies. The
ability of the Elekta Synergy® to acquire fast and detailed
soft tissue, target volume and critical structure information
at the time of treatment is the most practical, effective and,
most importantly for the patient, comfortable way to ensure
treatment accuracy.
Sophisticated imaging technology
The Elekta Synergy® comes available with a suite of
imaging tools on a fully digital Linear Accelerator completely
integrated and streamlined with state-of-the-art X-Ray
Volume Cone-Beam technology and an Electronic Portal
Imaging System.
• iViewGTTM Electronic Portal Imaging System
The iViewGTTM provides fast, high-resolution, highcontrast 2D megavoltage images of the patient in the
treatment position enabling quick real-time positional
verification during treatment delivery.
• 3D Volumetric imaging (VolumeViewTM)
Clinicians can visualize soft tissue detail with CT-like
contrast for any area of the body using the VolumeViewTM
imaging modality at the time of treatment. The system
provides volumetric 3D data sets with sub-millimeter
isotropic resolution. A single one-minute revolution
is sufficient for the system to acquire a complete 3D
volume. Reconstruction takes place simultaneously
making the image almost instantaneously available for
the clinician to analyze. Advanced automated registration
tools enable rapid registration of the 3D VolumeViewTM
image against the CT treatment plan image. This allows
clinicians to optimize their treatment plans and correct
for target shifts due to organ motion & deformation and
setup inaccuracies.
Key advantages offered by VolumeViewTM
imaging at the time of treatment include:
Rapid acquisition of hi-resolution, hi-contrast 3D images
with ultra-low imaging dose
Excellent soft tissue visualization & definition provide
critical anatomical data with reference to the tumor target
and surrounding organs at risk
Automatic bone or soft-tissue matching between planning
& in-treatment images provide sub-millimetric accuracy
eliminates the need for any skin or internally implanted
surrogate markers
Variable sized FOVs (field of view) and ultra-low imaging
dose settings optimize imaging for different areas of the
body
• MotionView™
Elekta Synergy® MotionView™ was developed to
overcome the problem of intrafractional organ motion,
eg, breathing. MotionView™ helps locate targets that
move on a high frequency basis, such as lung tumors.
MotionView™ is also useful for monitoring other motion
in the thoracic and abdominal regions, such as cardiac
rhythm and bowel movements.
Key advantages offered by MotionViewTM
imaging at the time of treatment include:
real-time movement of dense features
lung tumors (high contrast to air)
bony landmarks that do not overlie other bony features
implanted markers in soft tissue targets
• PlanarView™
Elekta Synergy® can produce PlanarView™ (2D)
radiographs at very low radiation doses for initial patient
set-up. While MotionView™ is useful for uncertainties
associated with intrafraction movement, PlanarView™
more specifically addresses interfraction movement of
the bony anatomy.
Key advantages offered by PlanarViewTM
imaging at the time of treatment include:
quick, low-dose, snapshot images showing dense
features
lung tumors (high contrast to air)
bony landmarks (that don’t overlie other bony features)
implanted markers in soft tissue targets
Image-guided stereotactic radiation treatment
The Elekta Synergy® system’s conventional Multileaf
Collimator Beam Shaping device can be further augmented
with the Dynamic Micro-Multileaf Collimator hi-definition
beam-shaping system. This configuration optimizes the
system to enable ultra-precise stereotactic radiation
therapy or single-session radiosurgery for the intracranial
indications.
Image guidance plays a critical role in compensating for
the intrafraction motion of internal organs in relation to bony
structures & soft tissue information and for interfractional
change in organ position that may compromise accurate
patient set-up between treatment sessions. The Elekta
Image-Guided Stereotactic treatment system ensures
that the highly conformal radiation beam precisely hits the
target and avoids surrounding critical structures through
comfortable, non-invasive patient immobilization and submillimteric internal anatomy position verification at the time
of treatment with 3D Image Guidance.
Case Study:
Dr John Low Seng Hooi
Consultant Clinical Oncologist
Cancer Institute
Pantai Hospital Kuala Lumpur
Application of Elekta Synergy® image
guided radiation therapy (IGRT) and
intensity modulated radiation therapy
(IMRT) in treatment of nasopharyngeal
carcinoma (NPC).
In a recent interview, Dr John Low, a clinical oncologist from Pantai Hospital Kuala Lumpur, shared
details of a case that was presented to him earlier this year. He spoke on the history, diagnosis and
application of the Elekta Synergy® system in treatment of the patient’s cancer.
Patient history:
A 35-year-old man was diagnosed with NPC stage IVB
(T4N3M0) in January 2008. When presented, clinical
examination revealed extensive bilateral swelling of the
neck nodes and numbness over the right V2 dermatomal
distribution. Medical imaging revealed a large tumor mass
with incracranial extension and bilateral enlarged cervical
lymph nodes more than 6 cm in size. There was no evidence
of distant spread of the cancer.
Planned treatment:
Contouring was carried out using the CMS FocalPro
workstation, and it should be noted that for IMRT, contouring
must take into consideration every single organ surrounding
the treatment area. Planning was then done using the CMS
XiO treatment planning system.
A nine beam IMRT plan was generated for treatment on
Elekta Synergy®. The approved treatment plan was 6996
cGy to the isocenter (CTV). DVH readings revealed that the
tumor received a mean dose of 7440 cGy. The surrounding
critical structures were all within tolerance. Dr Low stressed
on the importance of geometric accuracy during radiation
therapy due to the close proximity of critical structures (i.e.
brain stem, spinal cord and temporal lobes) to the high
dose targets. Elekta Synergy® Cone-Beam CT technology
ensured rapid daily correction of any target misalignment
to ensure the optimal geometric
accuracy.
The patient received a combination
of chemotherapy (cisplatin) and
radiation therapy. Chemotherapy was
administered once every three weeks
(concurrently with radiation), whereas
radiotherapy was continuous (33
times, fractionated). Total treatment
time was approximately six and a half
weeks.
Figure 1A: NPC at Day 1 of treatment
Elekta Synergy® IMRT and
IGRT produces remarkable
tumor shrinkage
Within a week of receiving treatment,
the affected lymph nodes had shrunk
to such an extent that planning had to
be carried out again. After just three
fractions of the IMRT treatment, IGRT
imaging showed that the lymph node
had shrunk by approximately 1.3 cm
(Figure 1A and Figure 1B). One of
the benefits of the Elekta Synergy®
system is that it offers more targeted
therapy, thus enabling physicians to
dose-escalate (inflict a higher dose of
radiation on the tumor). This, remarks
Dr Low, translates to improvement
in outcome, as has been shown in
various trials worldwide.1
Upon completion on treatment,
medical imaging revealed total
clearance of the tumor. Side effects
included minor burns on the skin and
mouth ulcers (caused by low-dose
scatter radiation). In addition, the
patient exhibited a significant weightloss of 7 kg, due in part to temporary
mouth ulcers and general discomfort.
Dr Low assured that all symptoms
were temporary and were expected to
clear within three to four weeks posttherapy.
Figure 1B: NPC after three fractions of IMRT treatment
Conclusion:
Post-therapy follow-ups reveal that the patient has responded well to therapy. With its 3D volumetric verification and online correction facility, physicians are now able to carry out more precise treatments. In addition, patients can rest assured
that with more targeted therapy, vital organs (i.e. brain stem and temporal lobes) that are in close proximity to the highdose regions, can be more confidently protected during irradiation.
This publication is made possible through an
educational grant from
Editorial development by CMPMedica Medical Education.
The opinions expressed in this publication are not necessarily those of the editor,
publisher or sponsor: Any liability or obligation for loss or damage howsoever
arising is hereby disclaimed. ©2008 CMPMedica. All rights reserved. No part of
this publication may be reproduced by any process in any language without the
written permission of the publisher. CMPMedica Pacific Limited, 9th Floor, CNT
Tower, 338 Hennessy Road, Wan Chai, Hong Kong. Enquiries: United Medica
Sdn Bhd, 5/F, Tower 2, Wisma MCIS Zurich, Jln Barat, 46200 Petaling Jaya, Selangor, Malaysia. Tel: (603) 7954 2910 Fax: (603) 7958 7853 E-mail: enquiry.
[email protected] Web site: www.asia.cmpmedica.com
MY-PAN-006
References:
1. Case studies on application of Elekta Synergy® in cancer therapy. Available at: http://www.elekta.com/healthcare_international_elekta_synergy.php.
Accessed 21 October, 2008
Inspiring clinical confidence
With Elekta Synergy, Pantai Hospital Kuala Lumpur offers the first advanced multi-functional linear accelerator with intensity modulated radiation therapy
(IMRT) and image guided radiation therapy (IGRT), enabling our clinicians to both image and treat patients in the same frame of reference, at the time of
treatment. The result is unmatched clinical confidence, enabling more aggressive treatment of tumors while minimizing damage to surrounding healthy
tissue.¹
Reference: 1. http://www.elekta.com/assets/compelling/proof_frames.html [Accessed: 5 November 2008]
Pantai Cancer Institute, Pantai Hospital Kuala Lumpur
No. 8, Jalan Bukit, 59100, Kuala Lumpur.
Tel: 03 2296 0888. Further information is available on request.
Image Guided Radiation Therapy
|
Intensity Modulated Radiation Therapy
|
Stereotactic Radiosurgery
|
Plan, Target & Treat in 3D
For healthcare professional use only
1-15 December 2008
www.medicaltribune.com
Introducing Elekta Synergy® at
Pantai Hospital Kuala Lumpur
Revolutionizing Cancer Treatment at Pantai Cancer Institute
with IMRT & IGRT via the Elekta Synergy® System
This reprint is made possible through an educational grant from Pantai Hospitals.
The opinions expressed in this publication are not necessarily those of the editor, publisher or sponsor. Any liability or obligation for loss or
damage howsoever arising is hereby disclaimed.
© 2009 CMPMedica. All rights reserved. No part of this publication may be reproduced by any process in any language without the written
permission of the publisher.
CMPMedica Pacific Limited.
9th Floor, CNT Tower, 338 Hennessy Road, Wan Chai, Hong Kong.
Enquiries: United Medica Sdn Bhd.
5/F, Tower 2, Wisma MCIS Zurich, Jln Barat, 46200 Petaling Jaya, Selangor, Malaysia.
Tel: +603 7954 2910 Fax: +603 7958 7853
Email [email protected] www.asia.cmpmedica.com
MY-MT/MO-RPT-146