Download Real-Time Intra-Fraction Target Tracking During Radiation Therapy

Real-Time Intra-Fraction Target Tracking During Radiation
Therapy
Policy Number:
MM.05.011
Line(s) of Business:
HMO; PPO; QUEST
Section:
Radiology
Place(s) of Service:
Outpatient
Original Effective Date:
02/01/2013
Current Effective Date:
02/01/2013
I. Description
Real-time intra-fraction target tracking, as an adjunct to the delivery of radiation therapy is defined
as techniques and devices that enable adjustment of the target radiation while it is being delivered
(i.e., intra-fraction adjustments) to compensate for movement of the organ inside the body. Realtime tracking is defined as frequent or continuous target tracking in the treatment room during
radiation therapy, with periodic or continuous adjustment to targeting made on the basis of target
motion detected by the tracking system. This policy does not address approaches used to optimize
consistency of patient positioning in setting up either the overall treatment plan or individual
treatment sessions (i.e., inter-fraction adjustments); instead it deals with approaches to monitor
target movement within a single treatment session.
During radiation therapy, it is important to target the tumor so that radiation treatment is
delivered to the tumor, but surrounding tissue is spared. This targeting seems increasingly
important as dose-escalation is used in an attempt to improve long-term tumor control and
improve patient survival. Over time, a number of approaches have evolved to improve targeting of
the radiation dose. Better targeting has been achieved through various approaches to radiation
therapy, such as 3-D conformal treatment and intensity-modulated radiation therapy (IMRT). For
prostate cancer, use of a rectal balloon has been reported to improve consistent positioning of the
prostate and thus reduce rectal tissue irradiation during radiation therapy treatment of prostate
cancer. In addition, more sophisticated imaging techniques, including use of implanted fiducial
markers, have been used to better position the tumor (patient) as part of treatment planning and
individual radiation treatment sessions.
This policy does not address inter-fraction image guided therapy, defined as techniques and
devices that can be used to guide radiation therapy prior to its delivery.
Real-Time Intra-Fraction Target Tracking During Radiation Therapy
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II. Policy Statement:
Real-time intra-fraction target tracking during individual radiation therapy treatment sessions is
not covered because there is no data indicating that the use of real-time tracking during radiation
therapy to adjust the intra-fraction dose of radiation therapy or monitor target motion during
radiation treatment improves clinical outcomes over existing techniques.
III. Administrative Guidelines:
Applicable code:
CPT code
0197T
Description
Intra-fraction localization and tracking of target or patient motion during
delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D
surface tracking), each fraction of treatment
IV. Rationale
Proponents of real time intra-fraction image guidance argue that these techniques improve
treatment accuracy, thereby reducing the likelihood of radiation induced complications and
potentially improving the effectiveness of radiation therapy. Therefore, validation of the clinical
utility of intra-fraction image guidance requires studies comparing this technology to standard
radiation delivery using inter-fraction guidance. To date, published studies have suggested
favorable outcomes with use of intra- fraction target guidance but have also acknowledged the
need for larger controlled trials to clarify the role of this technology in facilitating safer dose
escalation while reducing organ motion challenges and toxic effects to improve delivery to the
target volume for various sites, such as prostate, lung and breast (1, 2, 3, 4, 5).
A literature search identified two additional studies that address the Calypso System, as an adjunct
to prostate cancer radiation. Both of these studies focused on the technical capabilities of the
device and did not report clinical outcomes (6, 7). Kindblom published a feasibility study of the
RayPilot device in 10 subjects with prostate cancer, but no clinical results were reported (8).
Sandler and colleagues reported on 64 patients treated with IMRT for prostate cancer in the
Assessing the Impact of Margin Reduction (AIM) study (9). Patients were implanted with Beacon
transponders (Calypso Medical Technologies, Inc., Seattle, WA) and were treated with IMRT to a
nominal dose of 81 Gy in 1.8 Gy fractions. Patients in this study were treated with reduced tumor
margins, as well as real-time tumor tracking. Patient-reported morbidity associated with
radiotherapy was the primary outcome. Study participants were compared to historic controls.
Study participants reported fewer treatment-related symptoms and/or worsening of symptoms
after treatment than the comparison group. For example, the percentage of patients in the historic
comparison group reporting rectal urgency increased from 3% pre-treatment to 22% posttreatment, no increase was observed in the current experimental group.
Real-Time Intra-Fraction Target Tracking During Radiation Therapy
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Practice Guidelines and Position Statements
The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Prostate
Cancer state, "The accuracy of treatment should be improved by attention to daily prostate
localization with techniques, such as image guided radiation therapy (IGRT) using computed
tomography (CT), ultrasound implanted fiducials, electromagnetic targeting/tracking, or an
endorectal balloon to improve oncologic cure rates and reduce side effects." This NCCN guideline
for prostate cancer says, "IGRT is required for doses greater than or equal to 78 Gy." (10). These
guidelines do not mention the use of real-time intra-fraction target tracking or the specific use of
the Calypso 4D Localization System.
Summary
With no randomized trials that compare IMRT with real-time intra-fraction target tracking to IMRT
alone, it is not known whether the addition of real-time intra-fraction target tracking improves net
heath outcome (fewer adverse effects and/or improved survival). There is also no data supporting
the use of real-time tracking during radiation therapy to adjust the intra-fraction dose or monitor
target motion during radiation treatment improves clinical outcomes over existing techniques.
V. Important Reminder
The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not
intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is
intended to discourage or prohibit providing other medical advice or treatment deemed
appropriate by the treating physician.
Benefit determinations are subject to applicable member contract language. To the extent there
are any conflicts between these guidelines and the contract language, the contract language will
control.
This Medical Policy has been developed through consideration of the medical necessity criteria
under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4),
generally accepted standards of medical practice and review of medical literature and government
approval status. HMSA has determined that services not covered under this Medical Policy will not
be medically necessary under Hawaii law in most cases. If a treating physician disagrees with
HMSA’s determination as to medical necessity in a given case, the physician may request that
HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any
supporting documentation.
VI. References
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1. Li HS, Chetty IJ, Enke CA et al. Dosimetric consequences of intrafraction prostate motion. Int J
Radiat Oncol Biol Phys 2008; 71(3):801-12
2. Noel C, Parikh PJ, Roy M et al. Prediction of intrafraction prostate motion: accuracy of pre- and
post-treatment imaging and intermittent imaging. Int J Radiat Oncol Biol Phys 2009; 73(3):692-8
3. Santanam L, Malinowski K, Hubenshmidt J et al. Fiducial-based translational localization
accuracy of electromagnetic tracking system and on-board kilovoltage imaging system. Int J
Radiat Oncol Biol Phys 2008; 70(3):892-9
4. Smith RL, Lechleiter K, Malinowski K et al. Evaluation of linear accelerator gating with real-time
electromagnetic tracking. Int J Radiat Oncol Biol Phys 2009; 74(3):920-7
5. Tanyi JA, He T, Summers PA, et al. Assessment of planning target margins for intensitymodulated radiation therapy of the prostate gland: role of daily inter- and intra-fraction
motion. Int J Radiat Oncol Biol Phys. 2010; 1579-1585
6. Kupelian P, Willoughby T, Mahadevan A et al. Multi-institutional clinical experience with the
Calypso System in localization and continuous, real-time monitoring of the prostate gland
during external radiotherapy. Int J Radiat Oncol Biol Phys 2007; 67(4):1088-98
7. Willoughby TR, Kupelian PA, Pouliot J, et al. Target localization and real-time tracking using the
Calypso 4D localization system in patients with localized prostate cancer. Int J Radiat Oncol Biol
Phys. 2006; 65(2):528-534
8. Kindblom J, Ekelund-Olvenmark AM, Syren H et al. High precision transponder localization using
a novel electromagnetic positioning system in patients with localized prostate cancer.
Radiother Oncol 2009; 90(3):307-11
9. Sandler HM, Liu PY, Dunn RL et al. Reduction in patient-reported acute morbidity in prostate
cancer patients treated with 81-Gy intensity-modulated radiotherapy using reduced planning
target volume margins and electromagnetic tracking: assessing the impact of margin reduction
study. Urology 2010; 75(5):1004-08
10. NCCN Clinical Practice Guidelines in Oncology; Prostate Cancer. Version 3.2012
11. U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health (CDRH)
510(k) Premarket Notification Database. Calypso 4D Localization System. Summary of Safety
and Effectiveness. No. K060906. July 28, 2006
12. BCBSA Medical Policy Manual. Real-Time Intra-Fraction Target Tracking During Radiation.
Policy # 2.03.10. Last reviewed January 2012