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Individually adapted radiotherapy

Research area 3

Adaptive treatment planning: target, dose and fractionation
Development of individually adapted radiotherapy will be based on clinical radiobiological parameters and biological imaging as investigated in research areas 2 and 3. Based on configurative changes of tumour geometry, tumour biology and organs at risk, the possibilities and necessity to perform adaptive planning during radiotherapy will be evaluated. Full image guided dose planning based on 3D imaging will enable the delivery of very high doses of radiation tailored selectively to the cancer target in both space and time domains (4D). Resistant tumour subvolumes can be targeted with deliberate inhomogeneous dose distributions obtained with intensity modulated radiotherapy (IMRT) or brachytherapy. Figure 6 shows an example of dose painting with a brachytherapy needle implant. Tools for clinical implementation will be developed in relevant work packages, and full clinical implementation will be carried out in clinical protocols all based in the framework of CIRRO. Advanced tools for 3D dose reporting and analysis will be developed and implemented in a national database for treatment data and outcome for all patients undergoing RT. The long-term objective is to be able to individually adapt target, dose and fractionation based on 3D imaging, individual biology and risk estimation.
Target and fractionation concepts will be investigated in randomized trials in breast cancer (IP03a, IP03b), and risk estimation in individual patients will be modeled based on knowledge of tumour biology. Functional imaging will be utilized to improve target definition and radiotherapy technique in Hodgkin lymphoma (IP04) and cervical cancer (IP12), and the benefit of image guidance will be assessed in terms of risk estimation and clinical outcome, respectively.

Adaptation to geometrical and anatomical changes during radiotherapy
A fundamental challenge in obtaining true individualized radiotherapy is to account for each patient’s pattern of geometrical uncertainties in target position observed throughout treatment delivery, i.e. changes occurring both between and within each treatment fraction. The current project will address these issues for a number of tumour sites, covering head-and-neck, lung, prostate, cervical and bladder cancer, with an overall aim of developing adaptive IGRT into clinical maturity. As the technological solutions required will differ according to the specific clinical situation, the projects included will involve developmental work within practically all relevant technologies. For head-and neck and pelvic cancer, activities will focus on on-line volumetric imaging for treatment adaptation (IP01, WP06), with deformable registration for dose accumulation and statistical methods for optimal plan adaptation (WP03) as important building blocks. For abdominal targets, the above planning and delivery technologies will be expanded with 4-D RT technology (IP06), including 4D imaging techniques for planning (CT and PET/CT) (WP05) and adaptation (CBCT) (WP06). Investigations into the design and application of new markers and fiducial contrast agents will take place, with particular relevance for lung, prostate and bladder cancer (WP07, IP07). Across all IGRT applications, more fundamental development in the fields of image management (segmentation and registration) (WP03), dose verification (WP8), and rapid dose calculation will be the underlying requirements for the projects. Regarding treatment delivery, the project includes development and clinical protocols for new dose conformation technologies such as IMAT (IP08), gating and tracking (WP05, IP02), all making highly individualised RT possible.