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External Beam and Brachytherapy Treatment Planning: External beam and brachytherapy treatments are planned using the Computerized Medical Systems - FOCUS treatment planning computer. It is one of the most widely used commercial 3D treatment planning systems. It is an extremely fast computer system that allows for 3D reconstruction of the patient's anatomy including the tumor (a virtual 3D patient) from CT image studies and other data sets. Utilizing sophisticated Image Fusion Software it allows for matching MRI or nuclear medicine PET image studies with the CT created data, assisting the physician in visualizing tumor and surrounding tissues.

screenFor external beam planning, FOCUS allows the physician and physics team to simulate the precise placement of radiation beams, shielding blocks (to protect normal tissue) and sophisticated tissue compensators. It uses algorithms to calculate and display the resulting doses throughout the virtual patient area of interest. Using other complex analysis tools, FOCUS allows the team to evaluate and determine the optimum treatment for the patient.

The process of closely protecting normal tissues while maximizing the tumor dose is called conformal radiotherapy. The conformal delivery of treatment has been employed at the Hux Cancer Center since 1990.

In 2006, the Hux Cancer Center implemented the latest in external beam treatment planning delivery -- IMRT (Intensity Modulated Radiation Therapy). IMRT provides us with additional treatment options in designing the patient's treatment. In IMRT planning, the physician tells the computer the dose prescribed to the tumor and the limits that can be given to surrounding tissue. The computer then tries thousands of possibilities to come up with the ideal method to deliver the treatment. Multiple, highly collimated fixed beams, sliding windows or tissue compensators are used to deliver the intensity modulated treatment. Most patients are treated with a "step and shoot" IMRT process that incorporates sliding windows.

In 2010, the Hux Cancer Center implemented Monaco -- the newest CMS calculation platform. It uses a Monte Carlo calculation algorithm that is the first commercially available tool to use this methodology. Monte Carlo is considered the "holy grail" of radiation oncology physics, because it allows predication of the interaction of single xrays within the tissue volume and is much more precise than previous systems. Monaco reduces the time to develop IMRT treatment plans and cuts IMRT delivery time by a third. The Hux Cancer Center is one of the first radiation therapy facilities in the country to adopt Monaco. Funding for the technology was provided by a grant from the Union Hospital Foundation.

For brachytherapy planning, FOCUS allows the team to simulate the placement of sealed sources containing radioactive material within the patient. Using algorithms, the computer calculates and displays the resulting dose distribution within the patient in 3D. Utilizing complex analysis tools, Focus allows the team to adjust source placement to optimize the dose distribution, maximizing the dose to the tumor while minimizing the dose to surrounding tissues.

Prostate Seed Treatment Planning

Prostate Cancer Treatment Planning with radioactive seeds is performed on Varian's Variseed treatment planning system. This system is a specialized treatment planning computer, optimized for visualizing, calculating and evaluating the dose from implantation of seeds in the prostate. It allows for the virtual simulation of the prostate in 3D from imaging information acquired from either ultrasound or CT image data. Typically, the prostate and the position of surrounding tissues is downloaded from the data collected during an earlier ultrasound exam (volume study) of the prostate.

The prostate seed implant process is typically done in two visits. During the first visit, the prostate volume and conformation study is acquired and after the plan is developed and the seeds ordered, the patient returns for the actual placement of the seeds. It is possible to perform the procedure during one visit while the patient is in the operating room and asleep, but we rarely do this.

After the procedure is completed, the patient will usually have a CT scan of the prostate and that data is downloaded into the Variseed treatment planning computer. Using the specialized algorithms available on the planning system, the locations of the actual seeds are identified and the actual dose distribution is calculated for display and analysis. Using analysis tools, the physician can evaluate the actual treatment given. This is an aid in the patient's follow-up care and also provides quality assurance to confirm that an acceptable implant was done.

Radiation Delivery Equipment

ceilingThe Hux Cancer Center Radiation Oncology Division is equipped with two dual-energy linear Varian Clinac 2100C accelerators, a Varian fluoroscopic simulator and a Phillips Big Bore CT simulator. Most patients' simulations are done using the CT simulator.

Radiation production via a linear accelerator is the most modern way to deliver radiation therapy. The Cancer Center is equipped two Varian Clinac 2100C accelerators which have matched bean inventories of 6 and 15 MV xrays and 5 electron energies. Having matched beams allows us to move patients as needed between machines to minimize treatment waiting times. Both machines are equipped with portal imagers and robotic onboard imagers (OBI) for performing IGRT. Both have 120 leaf multi-leaf collimators. The Cancer Center physicians have a wide-beam inventory to allow them to choose the most precise radiation energy for treatment of a patient's cancer.

The Cancer Center also employs a full inventory of cesium brachytherapy sources. The Center is licensed for use of all currently available types of implantable radioactive seeds. These are obtained on an as-needed basis.

IGRT (Image Guided Radiotherapy) refers to a process that radiographically evaluates the patient position prior to treatment to ensure that there is no variation from day to day. This is done using robotic xray generators or cone beam CT scans. IGRT makes treatment delivery as precise as possible. All patients receiving XRT are evaluated daily with the IGRT process before their treatment is given. This is part of our concern that patients' receive the highest quality therapy.

Stereotactic Radiosurgery

The radiation oncologists at the Hux Cancer Center are part of a large statewide radiation oncology group. Two members of the group provide stereotactic radiosurgery at Saint Francis Hospital in Indianapolis using tomotherapy delivery system. Patients who have lesions that might benefit from stereotactic radiosurgery are discussed at the oncologist's weekly clinical review conferences and referral can be easily facilitated for those patients who are felt to be possible candidates.

Intraoperative Radiation

The Hux Cancer Center radiation oncologists have had a long association with CENTA (Center for Ear, Nose, Throat and Allergy) in Indianapolis. This is a premier group of head and neck surgeons who have a long and varied experience in the treatment of head and neck malignancy. Dr. Edward Krowiak has a biweekly head and neck tumor clinic in Terre Haute that is held at the Hux Cancer Center and is attended by Cancer Center radiation oncologists. Our radiation oncologists have, with the Head and Neck surgeons, the world's largest experience in intraoperative radiotherapy for head and neck cancer treatment. In intraoperative radiation therapy, a high dose of radiation is delivered directly to the tumor or tumor bed using electron beam therapy. The normal structures can be carefully shielded from the radiation beam and treatment is given directly to the exposed tumor during the operation. A number of patients treated at the Hux Cancer Center have had intraoperative radiotherapy during surgery for their cancer in Indianapolis at St. Vincent's Hospital.