Implementing SGRT for Stereotactic Treatments: Practical Steps for a Successful Start

Joana Gomes (00:04):

It’s a pleasure for me to be here today, presenting our experience with implementation of all AlignRT for ACTIC treatment. But as well, I will give you some information about how we implemented the system, the differences between the treatments without and with AlignRT. And finally, I will present you with some departmental data regarding treatment times for patients with stereotactic treatments and SGRT. Just a short overview. I work in Kantonsspital Winterthur and we have two Varian linear accelerators equipped with AlignRT and the CT with SimRT. And we have a satellite clinic inferior therapy routine. And there we have TrueBeam with AlignRT and also a CT with SimRT. We treat around 80 patients per day. And we treat around 40 patients per day. And now the question, why did we choose SGRT in 2020? Our goal was to give the patients the best treatments. And with SGRT we can increase the treatment accuracy, eliminate the need for tattoos in the clinic, and increase the clinical department efficiency as well. And be sure that during the treatment, the treatment will stop if the patient moves outside.

Joana Gomes (01:35):

Short overview about the implementation of SGRT, et cetera. We started there in September 2020. We followed a four-step plan recommended by the Vision RT team. We started with pelvic treatments, and then we moved to the thoracic treatments, and then we just started treating patients with breath-hold. When the team was comfortable with the system, the last group of patients were those with thermoplastic masks. So in less than 10 months, we could treat all our patients with the support of AlignRT. We follow the same step protocol in Winterthur, beginning with the easiest treatments and moving to the more complex as soon as the team feels comfortable and as well in 10 months or less than in 10 months, we could treat all our patients with AlignRT.

Joana Gomes (02:36):

And the combination of stereotactic and SGRT allows us to have the best of these two technologies. So we can treat very precisely in a single or a few high-dose sessions. We can assure that the patient has more comfort by eliminating, for example, the need for tattoos or permanent markings. And we can have the constant position control, sorry, for the presentation, it’s a bit different. But all of this comes at a cost, and the RTT teams are the most impacted ones as they need additional training in surface image, region of interest selection, SGRT system operator operation, as well as the medical office system. Because they are, they have a very important role as well in commissioning and in quality assurance. But this higher this needs for these trainings is very important because the consequences of this are very important for the patients.

Joana Gomes (03:46):

Just an overview about the beginning, when we started, we defined RTTs to be involved in the creation of the protocols together with the medical physics team. These protocols were defined, and we always keep them up to date with the feedback that the team gave in the use of the system. The medical physicists were with the team during the first treatments for the first weeks to be sure that everything was going well. We had one-to-one meetings to be sure that the team create the roles in a standard. And we had, and we are still having regular in-house trainings to keep the team up to date. So we started with a small team with these treatments, and then we just progressed to the complex treatments as soon as the team feel comfortable and always keeping the documents up to date

Joana Gomes (04:46):

Before I present you with the biggest differences between without and with AlignRT. Just looking back 20 years ago, when we treated our patients without SGRT, no daily imaging and a lot of skin marks and tattoos, it’s incredible to see how the workflows have changed since then and now with some more recent pictures. The biggest difference at CT is that we don’t need the tattoos or permanent markings. And we, we all are aware of how important this is for the patients because the tattoos have a big emotional impact on the patients, even when the treatment is finished at the linac. Before AlignRT, we aligned the patients with the skin marks or tattoos with the room laser. And in the past was less ergonomics for the team. And now with AlignRT, we can just use the data from AlignRT to move the patient on the table directly to the isocenter.

Joana Gomes (05:54):

And then when we leave the patient in the treatment room, and we start the treatment, we can see with the data from AlignRT if the patient’s still in the same position. Yes, it’s more information for the RTTs to manage, but the, the know the, the knowledge that during the treatment, the radiation will stop if the patient is outside of the tolerance gives the RTs. A very good feeling. And what is essential is that we have the troubleshooting documents up to date to know what we have to do if something un occurred happen. And this is the setup that we use we used in the past for SRS/SRT treatments, it was a closed face mask with a bite block. And since we introduced AlignRT, we treat our SRS/SRT patients with an open face mask and an individual pillow. And in the treatment room treating SR stereotactic patients, we align them having the tolerant the patient in less than one millimeter and one degree tolerance. And during the treatment, the system shows us if the patient is still in the position or not. And if not, as you can see here, it was in session, the patient could always be in the tolerance.

Joana Gomes (07:22):

Last year, two colleagues of mine did a retrospective study. They evaluated how was the, how is the setup accuracy between the open face masks that we used in the past and the close and the open face, sorry, in the past closed face masks and now the open face masks, they evaluated 90 patients in each group and the results showed that with open face masks, we have better setup accuracy and the needs for repositioning and repeat imaging is less. With an open face mask and SGRT, we expanded the, the, the study and we used these 180 patients, so around a thousand treatments to evaluate the treatment time between both groups. We defined the exclusion criteria. For example, patients with multiple isocenters or repeated CBCT were excluded from the group and patients with ex very excessive treatment times. For example, more than 25 minutes for the first session or 22 minutes for the subsequent sessions. This session specific were evaluated, and then we decided whether or not in the analysis.

Joana Gomes (08:36):

And as a result we could, we had six, almost 60 patients for the first session in each group, over face masks and SGRT and closed face masks. And for the subsequent sessions, we had more than 200 sessions to evaluate. And then the results show us that we have more or less for the first session, the same time around 22 minutes, and for the following sessions around 17 minutes. So the time was more or less this time, but what we analyzed is that the minimum time is shorter with the open face mask and SGRT. And this led us to reflect that there is a potential for improved department throughput with SGRT and open faced mask. And this was a point that, in the beginning of the use of SGRT and open face mask, this, this is a point that could influence negatively the results.

Joana Gomes (09:40):

And we believe that nowadays the treatment time is shorter with an open face mask. So it’s like a limitation. We believe that now the staff is more experienced and the treatment times are shorter. As I can show you here with these results, we evaluated the last four treated patients with SRT and AlignRT. And for the first session, the time is more or less one minute less compared with the past and for the subsequent sessions, more or less one and a half minutes. So we are quicker now with this experience. And now it’s more or less the idea that I would like to give you what comes next? So far, we treated our hidden neck patients with five-point masks and we were evaluating some different kinds of masks to offer to the patients. We chose this kind of mask, a chin mask, which we will use for the next patient’s hidden neck. We believe that this will give more comfort to the patients, and I hope that next year I’ll have some good results to present to you. In conclusion, SGRT is completely a, a powerful adjunct to stereotactic treatment, but not just for the stereotactic. Also, for the standard treatments, we believe that the treatments can be delivered faster and enhance the patient experience and comfort.

Joana Gomes (11:15):

And as a key takeaway, I like to do the comparison between driving a car without a seatbelt and radiotherapy, without SGRT, completely gives the security that a seatbelt can give to the driver when driving from point A to point B. Because if a situation occurs, something unexpected, we are sure that there is something there that will save the treatment. So it’s SGRT. Thank you. Thanks to the multidisciplinary team at Kantonsspital Winterthur and to Alessandro Kvi, the medical physicist in the department, who helped me with the statistical analysis and for sure to all the RTT team for their dedication. Thank you.