Heather Maurer March 2014 Adaptive Radiotherapy (ART) The term adaptive radiotherapy (ART) seems to be a fairly straight

forward term. It is radiotherapy that adapts, but to what, why and when are the questions. Many people may confuse ART with image guided radiation therapy (IGRT). These are two different concepts, though ART and IGRT are often times used in conjunction with one another. ART is the act of actually modifying the plan that the patient receives, or more commonly known as re-plans, while IGRT is most often moving or adjusting the patient to fit the plan better1. Re-plans can be done for many reasons, and according to some dosimetrists they can also be very aggravating, of course depending on the reason for the re-plan. Most re-plans are done due to changes in the patient that cannot be determined in the initial scan2. These re-plans are understandable; the aggravating ones tend to be when doctors just cant make up their minds, so Im told. ART replans occur in three timeframes, between treatments but during the same course, immediately prior to a treatment, and during a treatment1. At The University of Michigan ART re-plans are only done between treatments. They are currently participating in 3 protocols that include scheduled ART. There is a liver protocol that test liver function prior to simulation, then again after 3 Stereotactic Body radiation therapy treatments. With these results it is then determined if the patient will concluded treatment then or proceed receiving the additional 2 treatments at full dose or a fraction of the initially prescribed dose. A similar procedure happens for head and neck cases on protocol, though these cases will receive an additional CT scan to access tumor response. Their scan is scheduled to be when they reach 50 Gy and depending on the response, the GTV may be boosted with additional radiation while the other nodal volumes will continue with the original dosage. The national protocol they are taking part in is RTOG1106. This involves a PET scan to be performed on patients with non-small cell lung cancer (NSCLC) after approximately 19 of 30 treatments with a new plan being developed according to the PET scan. All other ART re-plans at The University of Michigan are determined throughout treatment by the physician and physics staff. These could be determined through CBCTs at the treatment unit noticing such things as tumor shrinkage or internal motion, or be due to the patients weight loss/gain or ill-fitting immobilization devices3. The following are some websites that were extremely helpful in explaining the concept of ART along with its advantages and limitations. http://medicaldosimetry.org/pub/39813d43-2354-d714-516b-e51adf7656b4 http://www.aapm.org/meetings/2011SS/documents/LangenAdaptive.pdf http://cancer.beaumont.edu/adaptive-radiation

The following images are examples of cases that require ART. Figure 1.3 The images on the right show tumor shrinkage compared to images on left

Figure 2.1 The image on the left shows the initial plan while the image on the right shows the change in anatomy by the first treatment fraction.

Figure 3.3 The top image is a CT slice from a simulation on 10/20/08 while the bottom image is a CT slice at approximately the same level from a re-simulation on 11/3/08

Figure 4.1 This image shows dose distributions of original plans on the original CT scan and then the original plan again on a later CT scan after the patient has experienced anatomical changes

Adaptive radiotherapy can be thought of as developing a plan to accomplish your set treatment goals then reassessing the progress or change in circumstances and adapting/modifying your approach to continue to achieve your goal. The following pictures may help you visualize it in a more creative non-medical way. Picture 1. Create your plan

Picture 2. Treat with your plan that allows dose to go where it needs to go.

Picture 3. Reassess to see if there are any changes and if dose is still going where it needs to go.

Picture 4. Create new modified plan

Picture 5. New plan adapted to the changes not accounted for in initial plan.

Picture 6. Resume treatment with new plan

References 1. Dong L. What do we know about Adaptive Radiotherapy? American Association of Medical Dosimetrists (AAMD) website. http://medicaldosimetry.org/pub/39813d432354-d714-516b-e51adf7656b4. September 2012, Accessed Feb 2014. 2. Langen K. Uncertainties and limitations in adaptive radiotherapy. AAPM website. http://www.aapm.org/meetings/2011SS/documents/LangenAdaptive.pdf. July 2011, Accessed February 2014 3. Fuss M. Adaptive Radiation Therapy. American Association of Medical Dosimetrists (AAMD) website. http://www.medicaldosimetry.org/pub/397412b7-2354-d714-512342b22b2c735d 2009, Accessed March 2014