Effectively Transitioning to Tattoo/Mark Free Radiation Therapy for All Treatment Sites

Jonathan Ortiz (00:04):

Okay, so as stated, this is about effectively transitioning to tattoo and mark free radiation therapy. You’ve already heard a lot about this from Justine and Emmy, so I’m just here to help any site that’s looking to do this can help make the transition.

Jonathan Ortiz (00:17):

So to be brief, introduction about where I work. So I work in Connecticut, which if you’re luckily enough to drive into, you’ll be greeted with this nice little sign. We are the self-appointed pizza capital of the country. I’m not saying I disagree a hundred percent with that, but it’s still a bold statement nonetheless.

Jonathan Ortiz (00:35):

So, our hospital is a 305 bed not-for-profit community teaching hospital. We have two TrueBeam’s. Unfortunately, we only have one AlignRT system at the moment, but Andy Klekar, if you’re around, I already asked what does the guy have to do to get our second one installed? Move us up the list. But so we are pending install of that second system. Once that second system is installed, we will be fully tattooless in markless. In the meantime, we’re tattooless, but we’re still doing marks, specifically for patients that have to be on the machine that doesn’t have a AlignRT. So that’s just a little picture of our cancer center. And we are a collaborative member of the Dana-Farber and Brigham Cancer Center. So we help share ideas and it really helps the community hospital, you know, really maintain that level of, integration and staying up to speed with the field.

Jonathan Ortiz (01:23):

So the agenda for today, we’ll be talking about what are some of the barriers to adoption of the tattooist markerless technique. Go through a basic workflow and the workflow adjustments necessary. Talk about the benefits over tattoo based setups and how do we ensure accuracy and reproducibility. And then troubleshooting, I had to take out, because it was a bit lengthy this talk, so hopefully some Q&A can help with that. And then some keys to be successful.

Jonathan Ortiz (01:49):

So what are the barriers? So I’ll explore each of these in depth more, but firstly I think is change. Tattoos and marks have been a part of our field for a very long time, and the idea of not having those can be a scary thought for some lack of experience, especially with the system itself. I think, there was someone who here who did a great talk last year about like, you can know how to use AlignRT but you don’t really know it. You know, you don’t really understand it fully enough to really embrace it. Comfort and familiarity, again, it goes back to that change aspect. You were comfortable with tattoos, we’re comfortable with marks. We can use AlignRT until something goes wrong. And then it’s like, now what? Now what do I do if I don’t know what to troubleshoot? And then the cost, which I’ll state it, we all know in this room it’s not cheap. So all the more reason to really in invest ourselves into it.

Jonathan Ortiz (02:36):

So firstly, I’ll discuss change tattoos. As I said, they have a long history in our field. They’ve been a vital part of the way we treat patients for many years. And it could take times for opinions to change. And with widespread adoption of new technologies, it really is incumbent upon those of us using it to really learn as much about it as we can to maximize its benefit. Many of us are so conditioned and used to tattoos, it does require sort of a reframing and a rethinking of patient setup. And not having a permanent mark to refer back to can make some uneasy. Because as we discussed earlier, what happens if the system goes down, which I’ll get to a little bit later. If not handled correctly, I think this can lead to some feelings of anxiety and making sure everyone is fully up to speed and is comfortable utilizing the system is important. If not, you can encounter some resistance. So as I mentioned, some rethinking, reframing no permanent reference point and if not handled correctly, can lead to some confusion, resistance, and in the end, change can be hard, but it doesn’t have to be. So my hope is that this talk helps anybody who’s looking to just take it that final mile.

Jonathan Ortiz (03:43):

Okay, so lack of experience. There is some, a little bit of a learning curve when you in first start incorporating this system. So that can be a challenge. Learning a new technique, new technology, figuring out how to adjust patients with this new technology and triangulate and angulate in a sort of a different way, without tattoos and deciding how to incorporate the technology into our practice. And this is an extremely important step to ensure everyone on the team feels comfortable. So it’s about how do we incorporate SGRT into our workflows? Not change them entirely, but how do we change the workflow itself around SGRT. Problem solving. That’s really what, when you start moving from knowing to really, truly understanding the system is you know how to troubleshoot. Something happens, you’re like, oh, I’ve seen this before, I know how to fix this. And problem solving, troubleshooting just two sides of the same coin.

Jonathan Ortiz (04:37):

So comfort and familiarity. So difficulties often arise when you first use the system and you’re encountering issues that you haven’t seen. For example, a lot of times what happens with breast patients is they’re swollen. So you’re seeing some, a lot of pitch issues that, pitch issues rotation role that you really don’t know how to correct. So like a really large role is an example of something that happened at a center I worked at where again, postural alignment, which you’ll hear me mention a lot in this talk, really helped us feel comfortable enough with the way we set her up in the room before we left, sort of ignoring the really large role that was like nine. And it turns out that’s because she had an expander that was sort of moving all over the breast. So we had to make an ROI that completely excluded that and we used that modified ROI for the rest of her treatments. So it does, some sometimes seem scary, like why is this happening? But I think when you see these issues more and more, you really learn how to troubleshoot them. And you know, like, okay, step one, I’m going to try this. Step two, I’m going to try that. And it really helps you get more comfortable with the system. So problems of this nature existed before we had SGRT, but with SGRT it makes them more apparent and we have to learn how to fix them.

Jonathan Ortiz (05:46):

The only way to overcome these is to determine sort of at the department level what the right course is going to be. And I think with this, which is what’s true with any new technology, is there’s going to be those naysayers in the beginning with experience. I think the more they use the system, the more they’re going to understand truly all the benefits it has, which I’ll explore in detail. And, they really learn how to maximize the system and its potential. And I feel SGRT is really one of those disruptive technologies in our field that has really drastically changed the way we look at setting up patients and especially how we monitor them throughout that treatment.

Jonathan Ortiz (06:21):

And then there’s cost. Anyone who’s been involved in these discussions knows it’s a pretty, pretty big sticker shock when you find out how much it costs. But I would say that makes it all the more, reason to really maximize its potential and not just use it for setup, not just use it for DIBH, but use it for everything. Use it for setup, use it for monitoring, and use it for every patient. And that really just helps maximize the investment in that technology.

Jonathan Ortiz (06:47):

So, a basic workflow and then how to make those adjustments when incorporating SGRT. So first step is always going to be prepare, prepare your patient if it’s a TrueBeam, prepare the beam, get your patient in the right position. And I would say at our center indexing is very important, especially as you’re starting to, what we’re doing in our department is limiting our mobilization. So not getting rid of it entirely, but that’s where the indexing really comes in handy. So you’re going to clinically straighten it, index your patient appropriately. This tells you that they’re in the right spot on that table so that when you do turn on the system, you’re not going to see something like that. So you see something like that, that should be jumping right at you and tell you they’re not in the right spot, I need to respond to that information. So in this case, you’re looking at that longitudinal value that tells you the patient needs to move towards the gantry. So while you could just move your whole table that way. You could be moving your table and then now you’re going to have a pitch that you didn’t have before. You might have a role that you didn’t have before. So this really helps is zero in on the patient position. And another thing we do at our center is we make sure that when before we leave that room, they’re set up to within one centimeter of those acquired couch values. So that sort of workflow we already have naturally makes sense with SGRT as you’re just making sure that before you leave that room, everything is as close to zero as you can get it. And we’re not just getting into the green. So if something like this were to happen, it could be our indexing, it could be the, in this case there was a backlog under the patient’s legs. It could be the backlog was in the wrong spot, we index in the wrong spot. And that’s why it’s important to respond to the information that the system’s giving you. Then you would just continue setting up your patient. And as a general rule of thumb, it’s good to start with your rotations, but if you do see something like what we just saw in that last picture, doesn’t mean you want to , you can’t just go back to the long fix and then go back to your rotations. There’s a lot of toggling back and forth. So often when new people, when I’m training new students or new therapists, that’s the one thing I’ll say is like, don’t get too rigid with how you approach the system. If you’re seeing something, respond to that first, then step into your adjusting your rotations, getting those close to zero and then transitioning over to your translations.

Jonathan Ortiz (08:58):

Then perform any pretreatment imaging, apply those shifts. And here’s another key difference is taking your reference capture. So depending on what that you want that reference capture to do, you either take it for this session only or you take it for this in future. And the only time we’re going to be taking it for this in future is if we want to negate or stop using our sim reference surface for setup and we want to transition over to this new reference surface. And I would say that happens very rarely. It’s typically in the case where a patient has had some significant surface changes between the sim and that time in treatment. An example that comes up is we had a patient, we were treating the, inguinal nodes and they lost quite a bit of weight. So we, the reference capture really helped limit the adjustments we had to make and gave us a more true representation of the patient’s surface. and then treat with intra fracture monitoring. So we also use beam control for every patient, different thresholds depending on what we’re treating. But again, it’s about maximizing this. Why should we be relying on manual beam hold when we have the system telling us the patient has moved?

Jonathan Ortiz (10:03):

Okay, so how do we incorporate SGRT? So this is obviously the biggest change, you know, it’s about how to deciding how and when it would enter the patient workflow, set a process. So as you’re making the transition, it’s often in conjunction with tattoos and it could be in conjunction with tattoos for a predefined amount of time. It could be, okay, we’re going to stop tattoo, but we’re just going to mark the patient. I think that’s something that should be determined at the department level. And it’s, I would say it’s based on the size of your department. So if you’re a larger institution, it might make sense to sort of stretch out that pilot period and maybe start one side at a time. But there’s value to either approach.

Jonathan Ortiz (10:43):

And I would say it’s time to start rethinking positioning and mobilization and it starts in the sim. You’ve heard that already today. And I think that’s always been true in our field, but even more so now. And it’s something that my colleague Matt and I will be talking about tomorrow. It’s about in your, when you’re in the sim it’s about how are we making this immobilization device with SGRT in mind? And how are we going to position this patient focus on the visibility for the cameras rather than truly immobilizing them. And it’s almost like using your mind’s eye where the cameras are in the room when you’re making that device.

Jonathan Ortiz (11:18):

Patient education, which is something we also heard about ready today. And I think the earlier you start this process, the better. Whether it’s in consult with the physician, whether it’s in the sim, we often do our education at our institution right before sim. So the patient kind of has an idea of what they’re about to step into. And I think it’s about explaining the reasons why or the why behind what we’re doing, especially when it leads means more what exposure for the patient. But the trade-off is we’re exposing you a little more, but it’s because we want the cameras to see. So we know that you’re in a position, we can confirm that you’re in the right position the entire time. So given that we’re asking our patient to be a little more physically exposed, I think it’s imperative that we explain the why behind it. And this is reinforced in sim, it’s reinforced at the first day or the verification simulation and throughout treatments.

Jonathan Ortiz (12:05):

Then here comes the downtime procedure. So it’s often not a very complex thing, but I think again, it starts in sim. So we also take our sim photos with the laser showing either our reference point or an ISO whatever, depending on what we did for that specific occasion. So we know, okay, if we don’t have an AlignRT which I’ll also add, I’ve been using it for six years, it’s happened once and it was a network issue, not Vision RT’s issue. So let the record show and it’s about, okay, we take our photos in the sim, here’s where the laser’s crossed. Okay, here’s the patient in front of me on the table, we’re in a good spot. Now I look at my indexing. Is my indexing appropriate? Is my patient clinically straight? Okay, let’s step out of the room and take our images because in the end we usually rely on internal imaging anyway. So that wouldn’t really change. We may get some larger shifts than we expect, but we would then involve the physicians, make sure the physician can review that image and decide what patients we’re going to treat during that downtime and which patients we wouldn’t. The ones that I would say for our specific center we wouldn’t be able to treat would be like a breath hold. But I hope that Vision RT stays true to its 99.9% uptime and we never have to encounter that issue.

Jonathan Ortiz (13:15):

And then, kind of show a little bit of this patient that shall not be named getting set up in a mask. can we play that video? So when you turn on the system, it’s often good to wait until your patient is in set in the setup position. The more you have the system on, the more data it creates, the slower your system becomes. So it’s about, again, you see my colleague here is pointing to those rotations, making those adjustments, fine-tuning those. And now there are some variables you can go through here. You’ll see the, the student actually who’s setting me up really got those down to as close to zero. Then put the mask on. You can sort of do an approach where you get them very close, put the mask on, but don’t put it all the way down. Make those final adjustments, then, attach it to whatever board you’re using. So customization, you know, depending on what your workflow is, is always advised. You don’t have to be so rigid with how you set things up. But the idea is you want those rotations like that, that’s a plus. And then you would make those final adjustments on the translations before starting your pretreatment imaging. So I’ll, I think you guys get the idea.

Jonathan Ortiz (14:24):

So one of the things that our Clin app who I know is not here, but shout outs to Kaitlyn Croy told us is that the earlier you start the monitoring, the more data it eats up on the system, which leads to more sort of freezing or any kind of glitches with the system. So she encouraged us to not hit play until the patient’s in position. And I would tell you it’s made a huge difference. We hardly ever have to deal with freezing or interruptions mid-treatment since we started doing that. So I highly recommend it.

Jonathan Ortiz (15:01):

Okay, so benefits over tattoo based setups. Firstly, would be accuracy. I’ll explain more of these in detail then would be safety, which is really how you get this, technology sold to the bore is patient safety. Efficiency, again, as Emmy mentioned and Justine mentioned, I think as therapists specifically, so much of our day is about how do I be more efficient than I was yesterday? So I think that’s something that this system really helps provide. Simplicity, using AlignRT can allow you to implement a simpler process, less shifting, less adjustments, less three points, then shift to an iso. All of that becomes sort of moot once you have this system. And then patient satisfaction and, something that I can’t go in depth too much to it today, but there’s some challenging setups that I’ve encountered that I felt like without SGRT, I don’t honestly think I would’ve, we would’ve been able to treat these patients.

Jonathan Ortiz (15:56):

So firstly, accuracy. So there’s just so much more information with AlignRT just as and as a point of example, it’s 20,000 points versus three. There’s just so much more information for you to use and to help refine your setup. And then postural alignment. I also want to know when did it change the Postural Video? Can anyone in here tell me? No? Okay, we’ll stick with the alignment then. The idea behind that, as we all know, those of you who don’t have it, I can’t say enough about it, buy it yesterday, you or have the ability to monitor the patient’s entire position. So you’re not just relying on your region of interest, you’re using it as a supplement and often you’re using it because your ROI is giving you some funky information and you’re like, but my postural alignment looks really good, so I’m going to continue on with this or I’m going to make an adjustment to my ROI until they both agree. So an example would be monitoring the patient’s chin position, especially when you’re treating nodes. It could be tracking the bolus position during treatment to make sure it doesn’t fall off or it’s in the right position. It could be something as simple as your CCTV goes out and you have no those three extra cameras in the room that you can monitor the patient with. And what it really helps is just refine your setup. Another example is at a center I worked at, we had a F head holder instead of a C. And by looking at the chin position, we were able to identify that. Another example was the, patient’s, apex of his lung wasn’t in the right spot because we were in the wrong indexing position. So all of these things are the information that the system gives you and I can’t talk enough about how good the system is for extremities, especially anything like a femur or humerus. It just really helps with those setups, as we all know can be truly, truly complex. Then surface deformation is something, I have a couple of slides on later, but it, it’s a tool that I never used too much until again Caitlin started showing me some ways that we can use it and to really identify the surface changes and sort of like carve out those on our ROI. Okay, and then 3D photos are another really nice feature that I have some slides about. So the 3D photo and the next, the another feature they have which is ROI metrics are sort of supplement to the postal alignment. While I would say postural alignment is one, the other two are one A and one B, they are supplementary, complimentary nature. But I think if you were to get just one postal alignment.

Jonathan Ortiz (18:26):

So the safety aspect, so you’re always setting up at your isocenter, this is one of those really key safety features that I think we often goes overlooked. There’s no separate three-point triangulation shift to an iso. It eliminates that possibility of error. There’s no shifting in the wrong direction, there’s no error in writing down the shifts and transposing them and executing them incorrectly. No more, as I said, no more incorrect shift, no wrong direction. Throw away those sticky notes that he bring into the room. Get rid of them, we don’t need THem. Patient movement, I often like to say that AlignRT is like the great un blinking eye in the sky, the therapist that never looks away, it’s that independent observer. Often as I believe Emmy or Justine mentioned, we are walking out the room, the patient moves a little bit thinking we’re not looking or they cough or something happens. We take our images and we’re like hmm, they set up really well in the room, what happened? We can now see if they’ve moved, we can adjust for it or we can feel confident that they move but settled right back into place. And I think that’s something that again often goes overlooked. There are often patients that are DIBH and they really struggle and they can drift outta position midway through the treatment. We can see that incorrect, and I think this safety aspect can’t be stressed enough with the increased responsibility on RTTs these days that we’re a compromising patient, treatment quality by not seeing and adjusting for this movement.

Jonathan Ortiz (19:49):

Efficiency. So what I think AlignRT gives us is faster and easier setups. We don’t need to adjust our pelvis patients specifically prostate patients nearly as much as we used to. So I’ve been at Stanford Health now for going on four months and that was one of the first things that we implemented was how do we use it for pelvis patients. And I think it’s really just led to a lot less manual manipulation of the patient, a lot less stress on our backs, moving them all over the place. And we often find that patients tend to sort of just lay in the general right position and just takes a little bit of fine tuning. We don’t need to hyperfocus anymore on the align to just three points and spend so much time getting those three points on. Less wasted movement built in SSD feature. I don’t know if you guys know about this one but it’s pretty nice. So if you are at a center that likes to cut these weekly or on the first day you get your patient set up and by the click of a button you can get all this information and as I mentioned earlier, but bears repeating extremities, whether the patient is frog left or I even treated this with the cubitus breast. Anyone can tell you those are very difficult. But with postural alignment specifically it makes those just as easy as the next.

Jonathan Ortiz (20:56):

And then onto simplicity. So a simplified process is a is available to us with less margin forever. Just simplicity is best. You have the ability to adjust patients and more emphasis on comfort and still maintain your accuracy. You can add certain things to the setup without compromising your accuracy because when you add it, you could see if it affected your setup. So if a patient is complaining that their back hurts a little bit, you can give them a little something and say okay, it didn’t mess anything up, we can, we can give you that. And it just really allows us to develop a more comfortable setup that’s still reproducible. So for example, I worked at a center that was going through a CT SIM replacement and not for all the patients but for some we were able to sim patients that had no bbs, no point of reference, no shift sheet, whatever it was. We just had a scan and a surface and that’s all we needed. And I think that’s that confidence that this gives you is that if I have a surface I can treat that patient. Another case was a loss backlog, another case was a deflated backlog. Both of those times there was no re sim needed and we were able to just reproduce that patient set up with our AlignRT system and it just leads to a much more streamlined approach.

Jonathan Ortiz (22:09):

So what tattoos and mark-less means is no more finding small tattoos, which I was guilty of. I’ll be honest, I made some very small tattoos so I was often yelled at for that. No more losing marks. So this still happens at our center because I know we, as I mentioned, we do still use marks, but one particular example that jumps out at me is a prone breast patient took off all the marks. We’re not going to get into why she did that, but she did and we were able to set that patient up on our AlignRT system, which at the moment we’re not using for prone breast only because of the way our patient population is divided up among machines. But we all were like, oh let’s just put it on our AlignRT and we’ll set her up and then we’ll give new marks for the other machine. So that’s the type of thing that this system gives you. And another thing that I have worked at institution where there was often lots of re-treatment with multiple tattoos. So I don’t know if you’ve been lucky enough to work at centers where it’s two tattoos, three tattoos, four tattoos. This really leads to no confusion with that and we don’t have to worry about that as therapists anymore when we walk into a room and great, the patient has no marks. Now what, alright, how many more patients we got coming or I’m gonna need you to call the one, the one 15, the one 30, ask them to come later. We don’t have to do that anymore. There’s no mixing up colors anymore. Whether it’s cone down primary first cone down, cone down, we don’t have to worry about that anymore. There’s no, even when you’re treating close to a prior site, we can still maintain that level of accuracy that we need.

Jonathan Ortiz (23:31):

So patient satisfaction, I think this was touched on already but again is worth mentioning again, what it gives us is less stress and anxiety for the patient. I often find that comes before they even enter our department, it’s about the discomfort they’re going to experience the increased emotional burden of this diagnosis, the permanent reminder of their, their journey in the lead up in simulation. I’ve had some patients cry when it’s time to get the tattoo and we always had to be in that awkward position of explaining or sort of encouraging them to get it and then stressing them out about like, well it’s going to stay there forever but maybe it’ll fade and we don’t have to worry about that anymore. I think what it also gives us is less stress about the patient maintaining those marks throughout treatment, especially on those hot summer days. And I think it gives us improved patient comfort. So it provides the patients that sense of ease and assurance that they’ll be treated correctly no matter what happens on that table. If they cough, if they move by accident, if they fall asleep and they, they jostle themselves awake, we can see everything and which is what I tell them as a warning, we can see everything. So even if they move inadvertently or cough or sneeze, we know immediately we can either confirm they’re still in the right position or we can correct their position. And then what it gives us is immobilization. Those considerations have changed now and less is more. We can make our patients more comfortable and thus less likely to move. If they’re claustrophobic, we can give them open masks, which leads to what I like to say is more of an passive way of immobilizing rather than active and not so much restricting movement but just helping them maintain that position. And open face masks, which I just mentioned is one of the major benefits and that’s where I think we see the most patients be really concerned and anxious about. And having that open face mask really limits that. And we can now in the sim focus on reproducibility and visibility for the cameras and not so much on immobilizing patients anymore.

Jonathan Ortiz (25:26):

So those challenging setups that I mentioned, one was an extended distance femur that the SGRT system really helped streamline the cubitus breast boost and some truly complex patient positioning. I’ll throw this up there, for you. But these two patients could not lay flat for treatment. They were in a sort of a semi seated, semi-supine position and there was, I can confidently say no way we would’ve reproduced these two positions without AlignRT. And I think it just gave us the confidence that despite what walks through those doors in our clinic, we can set that patient up and deliver that treatment and not have to send them away.

Jonathan Ortiz (26:05):

So how do we ensure our accuracy and reproducibility? So I think what the buzzword is at these conferences and especially today is ROIs. I think this is the single most important thing in this system, is creating ROIs that are reflective of the area that we’re treating and continually optimize those ROIs. I always tell, anyone I’m working with don’t get married to the first region of interest you draw, you can adjust those on the fly as much as necessary based on the information that it’s showing you. So sometimes it could be a poorly drawn ROI or it was placed over something that’s not patient anatomy. It’s drawn over an obstruction, it’s drawn in an area that the camera can’t see, it’s not on a blanket. For example, once the ROI is drawn, it can be modified so don’t stick with the first one, adjust as necessary.

Jonathan Ortiz (26:53):

Then I would say is respond to the information that the system’s giving you. And if your ROI is jumpy or unstable, if you’re finding the in room setup is not yielding the results you want, especially on internal imaging, it’s time to look at your region of interest. Then reference captures. So those break down into two different ones, which I think I mentioned already, but it’s this session only, this and future. If you find your setup with the CT SIM surface is not yielding the accurate results that you want with consistent shifts, then it’s time to think about, okay, maybe I need to set up on a good day and capture that new reference and then save that one for this in future sessions. And then these features that I think are really beneficial in maintaining or that level of accuracy is postal alignment one, number one. Then ROI metrics is a really cool feature that I’ve worked with before. So it sort of gives you that immediate response about the ROI you’re drawing and whether it’s too small, too large, too flat and there’s not enough topography and you can modify it right then and there when you’re importing the patient rather than waiting to see what happens when the patient’s already on the table. Then Surface Deformation. So that’s something I’ve been really trying to tinker around with now how to use that. And the 3D photo, which is sort of a really, really high definition picture of when you take that in-room reference capture. And I would say the most common utilization is on an SRS case where you really want to , might make sure your ROI is big enough and is not over the mask.

Jonathan Ortiz (28:19):

So Postural Alignment. So again, I’m going to really beat this horse. It allows us to provide that real time feedback utilizing that high quality live video and adjust the patient’s body position in real time and correct for that posture. Then the ROI metrics helps us draw those ROIs and get immediate feedback concerning the topography size and accurately monitor our patient. And then surface deformation, it helps us visualize any variation in the surface delineate areas of the surface changes and make adjustments based off of that information. So the most common example is like breast swelling or it could be your knee roll is too high and it would help identify that specific spot that is, that needs to be adjusted. So I would say each one of these alone is really beneficial and critical and they’re complimentary. But number one is Postural Alignment. And the 3D photo is, as I said, it’s that highly detailed image in the room and helps you clearly identify patient anatomy versus other obstructions. So you might’ve seen this next video before, but for those that don’t have postural alignment you can raise your hand in shame. It’s okay, it’s okay. This really is just a nice video that shows you what it gives you and how the regions of interest change based off of the changes in the patient’s overall position rather than just what the region of interest is showing you. So credit to Vision RT, this is on their website so feel free to, there’s a lot of good stuff on there.

Jonathan Ortiz (29:44):

So then ROI metrics. So this is what it looks like. We’ll be lucky enough to get this on our new system and then maybe we’ll be good enough at explaining to the board why we should have it on our other one. But what it does is you draw your region of interest and it gives that little blurb, okay, and this case I definitely cannot read that, but it might say this is too flat for accurate monitoring. Then you would go back in and adjust until you get two green checks and two green checks tell you good to go, you’re good to go. Two green checks means it’s a good size, it’s got good topography for accurate monitoring. If not, you’ll see those two error messages there. It may be too flat or it may result in slow monitoring if it’s too, too large and it may give you poor performance if it’s too small.

Jonathan Ortiz (30:29):

So this is the surfaced formation slide that I found really helpful. Again, a lot of this comes from Vision RT but the top right corner was sort of something that Kaitlyn showed me where you use the surface deformation with a treatment capture. So it overlays all the surface changes over the entirety of that patient scan. So you can truly identify where the adjustments need to be made.

Jonathan Ortiz (30:53):

And then 3D photo really gets you to see me in high detail. So there’s a comparison of what you’ll see, with 3D photo versus the standard reference capture. So it is very highly detailed and I would say the most, common use is when we’re doing SRS and you’re dealing with those really small, region of interest, often with, couch kicks that can lead to some camera obstruction. So the detail is really, really beneficial.

Jonathan Ortiz (31:21):

So, troubleshooting, do I have time for that? Maybe I’ll skip through this quickly. Jumpy dial says error messages bolus. Okay. Sorry. Oh wait, there it is. This is where I needed to be. Okay.

Jonathan Ortiz (31:39):

Keys to being successful. Training is the number one thing. Make sure your staff is adequately trained and comfortable before making that transition. I would say it’s good to sort of have a pilot, whether that means we’re going to pilot for all sites for three months, then remove the tattoos or we’re going to go site by site. Again, that should be determined at your department level and it’s about getting the buy-in and support, especially from administration, your physicians physics and dosimetry that really helps everyone feel like they’re adequately supported to make this this endeavor. Then it’s good to formulate some sort of implementation plan. You know, as for a department like ours that is sort of smaller, this becomes easierbecause you can get everyone in the same room at the same time, but having at least a well thought out roadmap of how you get there is important.

Jonathan Ortiz (32:26):

So training, so proper training is a must. This is a complex system that if not used properly can lead to really frustration and lead to a lot of places saying, oh, we tried AlignRT, we’re not going to use that. It doesn’t work. So the training from Vision RT is broken up into three phases, as many of you know we’ll be getting this with our new system. But phase one is sort of that, that first training, whether it’s at their Vision RT Center or in your clinic, where you get the high level view of what the system is. Then it leads into phase two where you get those webinars and everyone gets to get the same level of training and be prepared for the onsite visit, which is when the, the Clin App comes on site for at least two, two or three days while you’re implementing the system.

Jonathan Ortiz (33:08):

Then you could identify your super users. Again at a small start like ours, I want all of our staff to feel like super users, but at a larger institution it’s good to have those go-to people for the staff to really go to with questions and for troubleshooting help. And they can act as those in-house experts, especially when the Clin App leaves. They don’t feel like they’ve been abandoned. And it’s good to have those clin apps on site during that go-live. Whether it’s go live with the new system or go live with the tattoos and mark list. It’s really helps to everyone to feel comfortable with that transition. And the ongoing, support provided by Vision RT. We take advantage of this annual training. I know some of you may be taking advantage by coming here, but the support from Vision RT has always been there and I think that’s what puts them above and beyond the rest in this space is the customer support is always very quick and very detailed no matter what it is that you’re encountering. And then attending community meetings like this and presentations at, you know, the SGRT conference and really helping to tinker at the margins with what we’re using SGRT for and really unlocking its full potential.

Jonathan Ortiz (34:15):

Then that pilot project again, so it could be slow incorporation of SGRT, it could be one site at a time. You could set up as normal with tattoos and then implement SGRT. I will say that does add a little bit of time, but it’s about what makes the most sense for your center to get accustomed to the system and gain the confidence and experience that you need. Then expand its utilization to include more treatment sites if that’s the route you go. There’s also the rip the band aid off approach. So it really just, it’s about what works for your team. I think ultimately the right approach needs to be determined with all those parties involved. It could be the all in approach. It could be the camera’s not working approach.

Jonathan Ortiz (34:55):

It’s the buy-in and support that I mentioned earlier. So it’s important for the staff that they feel that support before they continue on with this, this implementation. They need to know the organization is committed to the technology they’ve bought into its utilization. They see the reason why we want to utilize it. I think often us as therapists are the biggest champions of this technology and it’s incumbent upon us to explain that, why we need that support. So we feel like we can continue utilizing it. SGRT systems, as I mentioned earlier, are not cheap. So it makes it even more important that we maximize the investment that the organization has made in this technology and not just use it for DIBH. We want to embrace it in order to have an effective rollout. So that buy-in and support should be from therapists first and foremost. Then it should be from leadership physics to symmetry physicians. Everyone needs to be on board.

Jonathan Ortiz (35:47):

And then, so some suggestions I would say that have worked in my experience. So I come from a center that was tattoos and Marks, I helped spearhead that effort. And now where I, at Stanford, I’m helping push us towards that as soon as we get our, our second system. So again, this depends on the size of your center, but you can formulate sort of a team, multidisciplinary team that can discuss the implementation plan before widespread adoption. You can formulate an SGRT committee and have all roles represented on that to discuss the right course of action. You want to establish those SOPs and protocols and this steps becomes even more important with a larger institution, regional cross coverage and traveling staff. As is becoming the norm. As these institutions get larger and larger, you want to reassess and revise everything that has to do with this. It could be the policies, it could be the regions of interest, it could be the protocols. You want to continuously evaluate those to make sure they’re working and they make sense. Again, just like you don’t want to get married to that first ROI, you don’t want to get married to the first thing you had before you started this program. You want to learn, you want to really implement the lessons learned. So as you build trust with the system, there may be some initial hesitation, but it makes it more important to truly demonstrate the value with the set, increased setup accuracy, the errors that are being caught, the image matching improvements and the decreased treatment times. Continuously evaluate your regions of interest, your workflows, your protocols as I mentioned. You know, don’t just stick with the first thing you decide upon. And then lastly, but not lastly, it’s collaborate with those Vision RT clin apps. They’ve been really helpful for me as I’ve really helped incorporate this system at now two different locations to help reinforce either what I’m saying or maybe fill in any gaps that I may have as we incorporate new things that we haven’t seen before at the center. And I would say again, a shout out goes to, Caitlin as a previous center I worked at, she was really instrumental in helping us with our first, prone breast that came across and really got us in a really good place for something that we didn’t do all that often.

Jonathan Ortiz (37:46):

So in the end, if I do nothing else today, if I can get everyone in this room from here to here, that’s a win. So in summary, tattoo and mark-free treatments with AlignRT can be utilized for both set up and motion management for any treatment site. Submillimeter accuracy in any treatment position, it offers us the potential to have faster, more accurate treatments, assist with highly complex patient setups, and with proper training and support, any size radiation oncology center can transition successfully. SGRT is, I believe, becoming the standard of care in radiation oncology and tattoo and mark free treatments are just the next step in that evolution. So thank you.