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Sponsored Advertorial 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