Wendy Tisue, MBA, RT(R)(T) (00:00):

Hello, my name is Wendy, and today I would like to talk with you all about SGRT and the challenges that we face in protons.

Wendy Tisue, MBA, RT(R)(T) (00:06):

Alright, so, this is an actual one, one of our, Hitachi ProBeam Gantries. We have four half gantry systems. We don’t have any full gantry systems at our clinic. This is what we use, for any anterior tumors that we’re treating, like perinasal sinus brain tumors, that would be close to the surface, but that’s called a bolus helmet. That’s something that was 3D printed for us up at in Rochester. And that has been very valuable for our center as well. But you can actually see our cameras. We have one mounted there over to the side, and then there’s one at the foot end and that those camera positions were very beneficial for our site, especially with the couch rotating all the way around, to both sides with the half gantry. And I have no disclosures.

Wendy Tisue, MBA, RT(R)(T) (00:56):

And, so today’s agenda, I’ll discuss transitioning from C-RAD to AlignRT, designing your proton room treatment sites that we utilize AlignRT with, challenges that we faced going tattoo-less, and then our verification scan challenges.

Wendy Tisue, MBA, RT(R)(T) (01:20):

So our proton center initially opened with having C-RAD as an SGRT system in just one of our four proton vaults. We decided to change to AlignRT due to the difficulties with the C-RAD system and the AlignRT system provided a more friendly user interface for the therapist. This change allowed us to have one vendor department wide since the photon site already had AlignRT. And with having the background C-RAD this did help the proton therapist to be more receptive to learning another new product because you know how excited they always get when they have to learn new products every other year. but since we already had C-RAD in one room, we installed Vision RT in the other three rooms first, and then once those three rooms were up and running, we then swapped out the C-RAD system to AlignRT. And then we initially started, treating our patient, our prostate patients, our breast, and our CSI cases, with, with AlignRT. And then after that we transitioned to open face masks and we are now using AlignRT anytime there’s an opportunity. So meaning anytime that we have a non masked patient will automatically use it for our setup and our monitoring. And I will go into more in depth of our transition from C-RAD to AlignRT and my other presentation tomorrow.

Wendy Tisue, MBA, RT(R)(T) (02:43):

So our room design and half gantry room issues. So these rooms do pose many challenges, but they can be overcome to help find the best solution for your particular clinic. If you do have more than one room, I would highly recommend installing it and commissioning the first room before you go to the other three rooms. and this just helps to ensure that the camera placement’s optimal. And we also did encounter an issue with needing to reinforce our camera brackets. And that was due to the vibration of, you know, these huge gantries rotating. So just have that in mind. But, Vision RT was able to troubleshoot all that for us, got the right brackets in, and we haven’t had any issues with that since.

Wendy Tisue, MBA, RT(R)(T) (03:26):

Another unique thing that our center has is apparently we were the first system to ask for three monitors for each room. So we have the monitors, actually one outside in the control room, and then we have a monitor in the treatment room, like where you’re actually setting your patient up. But then we also have an in-room imaging suite so that we can, you know, pop behind the wall, do all of our imaging, and then we go out. So we actually have one of those in three. We have one in each of the three areas. and that’s provided us with the ability to easily see and recapture the patient at any time needed. Right here our therapists use like some translucent paper and then they actually put cheaters on. It says like right left in soup table down and up, chin up, chin down, roll your left side up, roll your right side up hips, right hips left. And that’s because we can’t send the coordinates to the couch. We have to move our patient rather than the system correcting the table for us. this helps the therapists kind of with that anxiety feeling like, oh my God, I see these red bars going to either side, but I don’t know how to correct for it. Which way do I move my patient? So this was just like a quick little cheater for our therapist. Some don’t need it any longer. They’ve took, they’ve taken those cheaters off other people, they like them, and as they rotate onto their machines, they’ll stick them back up. So whatever helps your therapist be more the most comfortable, that’s what I would say do to to help them.

Wendy Tisue, MBA, RT(R)(T) (05:01):

So one of the initial struggles, that staff encountered when starting to use SGRT was when there was a discrepancy between the SGRT system and imaging. If they encounter this, they have been instructed that imaging will always take precedence over the SGRT system, but we did need to understand why there was a discrepancy and was there a solution to it. So they learned that the way an ROI is drawn can, change how well the SGRT system aligns. So the pelvis tends to be one of those tricky sites, that they’ve gone back and forth with the ROI shape. especially with having that little strip across the belly. we found that sometimes when patients are larger, that strip can be a hindrance more than a help. but it can also be helpful, especially if you have a half gantry and you have to rotate the couch back and forth. So some of our larger patients, we do have to keep it off, but some of them we do like to keep it on just so we don’t have that camera flickering issue. But we do also ensure to exclude the buttocks, and then also going too low into the leg, because that can introduce some unnecessary pitch issues that aren’t really there. And then you notice that when you take your x-rays.

Wendy Tisue, MBA, RT(R)(T) (06:16):

Here’s an example of a prostate ROI. You can see in this example that we did not include the belly strip. so our prostate setups, include a CIVCO, leg immobilizer that’s always indexed, in a standard position for all patients. Our center is very big on indexing every patient. I can’t think of any site that the patient’s just laying on the table without being indexed in some manner. This eliminates the need to make vac locks, it saves, storage space. It eliminates the issue of having the bags deflate, which if you use vac locks, we’ve all had that at one point or another where you put a device into storage, it deflates on you and then you’re either calling the patient back for a recent or fixing it on the first day. So we did exclude the belly strip on this example. And then, like I said earlier, we avoid going too low on the leg, for the pitch issues. And then once again, we excluded the buttocks and then we also make sure that we do not have any bunched up jeans or pants underneath the patient. I know some centers they don’t have their patients change a lot and just have them kind of lift up their shirts or lower their pants, but then you have all this material bunched up under you. And especially in protons, we don’t have the luxury of having some something introduced, into the treatment area. We need it to be as precise as possible. so we’re, we’re pretty strict on that. If the patients don’t wanna change into the scrub pants that we have at work, we just instructed them to wear, you know, like pajama pants or basketball shorts, something like that that they can easily lower. That won’t be all bunchy but no belts.

Wendy Tisue, MBA, RT(R)(T) (08:00):

Here is one of our, breast ROIs that we drew. So our breast set up consists of the Orfit system. We do have the AIO system for orit, but for this particular setup they just have it’s like a little black breastplate that we put on the table with a lock bar and then we utilize the back lock and then we also use the orit knee cushion. And then we also document which risk the patient is holding and then we have them turn their head. So you can see that we do, scan pretty high for CT sims. Somebody did ask a question in an earlier talk, like, how high do you guys scan for your, your breast patients? We, we like to go high for our dosimetrist, but then it also helps to provide a nice, a nice image for the therapist to utilize for the postural alignment to know exactly where those elbows supposed to be the head turned, is that correct? So it shows which wrist we have their head turned and then variant or vision has allowed us to ensure that the arms and chin are always in the correct position. And then many of our breasts are reconstructed breast patients. So we don’t have a lot of the pendulum breasts over in protons, but when we do, sometimes we’ll exclude the breast tissue and draw more of a ROI across the clavicles and the sternum. And that’s helped sometimes with, you know, the breast tissue. another thing to note though, with protons and breasts, we do, when we first started we had a mask set up, but then since utilizing vision that allowed us to go mask list for a setup, the exclusion for that is when we treat bilateral breasts, we do still utilize a mask system just because you don’t wanna graze into the other breast at all and the position for the actual breast tissue is very critical.

Wendy Tisue, MBA, RT(R)(T) (09:55):

CSI and SGRT, one of our biggest challenges with CSI setups was the alignment process. We see a lot of CSI treatments and this is a site that is not easy to image or treat and we do have a great setup for CSI by utilizing a body fix bag in the CDR head frame and mask. And the next part that was needed to improve upon was the imaging struggles. So before SGRT, we were imaging the brain then all the way down the spine to ensure that the body was perfect before we started to treat. And then SGRT has allowed us to reduce some of the initial imaging at table 270 and table 270 for us is our home position. That would kind of be like a linac table zero. And this is where we always do our initial imaging, with our 45 degree like images.

Wendy Tisue, MBA, RT(R)(T) (10:46):

So we don’t have a nice pretty AP and a lateral, we have 45 degree images. So with SGRT we were able to go from imaging the brain and all the way down the spine to just imaging the brain and then ensuring that the body was aligned with SGRT before we kicked the couch over to that first treatment angle. And once we kicked the couch to the first angle, we then imaged and treated the brain. After we treated the brain, we would then shift down to the spine, imaged there this time and make sure everything looked perfect and then we would proceed with treating the spine. And by doing this method, it saved us about 15 to 20 minutes of extra imaging, and going, between the isocenter. Okay, so it saved us about 15 to 20 minutes of extra imaging and going between isocenter in the beginning, but on the first day we will still image, the lower spine at table two 70 just to ensure that between imaging and AlignRT, that there’s no big deviations, that it all makes sense. And then when we draw the ROIs for csis, we only use one of the spine isocenter. We do not set up ROIs for each of the ISOs in vision, since we’re not typically using vision to check the head position. That’s another reason why we don’t do the head one. The photo on the left is of a pediatric patient and the therapist drew the ROI across the chest and then the mids spine and then the hips and then the adult patient on the right, he had a larger belly so they drew it across the chest again and then used the hips, kind of like prostate ROI. And since we only use the one ISO on AlignRT once we start treating and then we shift down to the lower spine iso, we’ll actually recapture for the day and then use that for monitoring only. And then we shift to the next ISO and then do it again. So CSI are kind of a complex one. Emily was great with helping us figure out a workflow. You know, do we actually wanna switch between all the three different ISOs or do we just wanna use it more for making sure your spine’s nice and straight. The question was do we do spine imaging at all? So on the first day we’ll image the brain and then we’ll align with AlignRT and then we’ll still image the spine on that first day. But once we know that yes vision, yes the x-rays agree with each other on the subsequent days, we’ll image the brain, make sure that the spine’s straight with vision and then we don’t spend another 10, 15 minutes imaging at table 270. We’ll just kick right over to our first treatment angle, start treating with the brain. But then when we shift onto to the spine ISO there, we still image there. And our physicists, they’ve created something called a bounding box for our CSI. Josh Stoker did that. and so that has a built in kind of tolerance that as long as that spine is within this bounding box that we know that we’re treating to the proper dose. So then that way we’re not fuzzing with like the super small millimeter shifts. just if as long as that spine’s in the box, then we’re good to treat. So that’s really helped the process as well.

Speaker 2 (14:15):

Is that the most included process?

Wendy Tisue, MBA, RT(R)(T) (14:19):

Yes. Josh, if you guys have any questions with the CSI planning Josh Stoker, I could get the contact information for you and I’m, he’d be happy to share that.

Wendy Tisue, MBA, RT(R)(T) (14:31):

Yep, yep. So we’re just using the one, spine ISO and then we’re able to use this for either ISO

Speaker 4 (14:42):

And do you ever have an issue when you’re using ISO cameras?

Wendy Tisue, MBA, RT(R)(T) (14:49):

So what they’ll do, so say this is like the soup spine ISO, for that larger patient, if they have a second spine ISO, we’ll you know, go to the treatment parameters of whichever one it’s drawn on first. So say it’s the soup iso, we know it looks great there, we x-ray and then we capture for the next day only and then we know when we go to the next ISO center that it’s gonna look off. So we just automatically recapture it again. But then we’re still always imaging with x-rays to make sure that it looks good. So essentially we just use this on the very first spine iso to know that your patient’s body is straight. We, we just kind of trick the system to let us keep going.

Wendy Tisue, MBA, RT(R)(T) (15:34):

So open face masks, they’re our latest adventure at our proton site. So our boss masks, they’re not a fan favorite, due to the inability for the therapist to see through them the rigidness of the masks and the difficulty with fastening, to the ball board, but they do their job well and we do have a very low replan rate for head and neck and brain cases. So when we asked about changing the setup from the closed face mask to the open face mask, our physics and our physician group were very hesitant. So we proposed doing an evaluation of the two open face mask types and compare the findings against the closed face masks with the similar disease sites. So we had a total of 10 open face, head and neck masks and 11 of the short masks. And we did a retrospective analysis of the number of re-setups, number of replants and the setup issues. We also looked at image guidance shift information exported from Aria and this was analyzed in Excel for, for statistical significance using the student’s T-test. And the calculations and assumptions were peer reviewed by physics and they found that they only had a lateral shift, on the open versus closed long mask that was found to be statistically significant. And the difference was a p value of a whole whopping 0.02. So their interpretation of the data is that the mobilization is not compromised by using the open faced version of the mask. And after the evaluation was complete, the physician group agreed to transition to the open face mask with the exclusion of perinasal sinus and their cord and the chords. And that’s also primarily because we would use that bolus helmet that I showed you in that first screen. So the bolus helmet is essentially covering everything that vision could see. So we just wanna make sure that the patient would have less of a chance to move. So if we’re using the bolus helmet, we would use the closed face mask, and not utilize vision for that for any of our open face masks. they’re not utilizing the bolus helmet, so we use vision for setup and for monitoring. So with the new setup, our, so with the new open phase setup, we did find that our patients are less anxious. The setup times have decreased, due to less resets as well. And in the beginning we did have some challenges with the system saying that we needed a pitch. but when we would x-ray the, the x-rays would find the opposite. So we found out from the trainers that we were not stretching the opening of the, open face mask down low enough to the anterior part of the ear, or we were having the ROIs actually go too low and they were touching the mask, which would cause inaccurate deviations. so by fixing those two issues, that has helped, with those pitch issues. right now our biggest challenge is noticing that there is some gapping in the mask at the forehead and this may be due to using a shim when making the mask. So we’re in the process right now of trailing no shims on five patients to see if we notice an improvement at all.

Wendy Tisue, MBA, RT(R)(T) (18:45):

We are now using a AlignRT for any non masked setup, in protons. And the pediatric patient on the top was having their whole right lung treated and Vision RT was very helpful with allowing us to avoid tattooing the patient for these treatments. And the patient on the lower left was also a lung patient. Typically we have adult patients in an orphan mass to help limit, the chest movement and reduce breathing motion as well. But she did have an allergic reaction to the mask, so we had to modify her setup to a vac lock wing board setup, with just a knee cushion and we were able to use the postural alignment to ensure her chin was also in the proper position since it was a higher lesion as well as to help position her body daily and monitor her for movement. And so far no issue. So we’re hoping maybe we could convince physics and the physicians to maybe go to more of a massless setup, especially when we know that there is just one cm or less of that tumor motion. The patient on the lower right was having their right thigh sarcoma treated and you may notice the bolus on the opposite leg and the genitals, this was to help protect his anatomy from getting any dosed, due to the ankles of the beams needed for his treatment. And we were able to use AlignRT to help not only with the positioning of his leg, but to also help with the positioning of the bolus.

Wendy Tisue, MBA, RT(R)(T) (20:12):

Tattoo list challenges. So being tattoo list is amazing, but it can have its challenges, especially for protons. if the system is down for treatment for our breast cases, our sim does have kind of a protocol that they do for our breast and our prostate cases to help, document some distances. So sim will actually document the distance from the sternal notch to the CT origin. And CT origin is just where we drop our, our treatment ISO, and dosimetry will provide any per plan shifts from there. But due to having robotic couches, we do utilize an Excel sheet that helps us calculate the table coordinates for the patient’s setup, and these calculations are actually inputted into, treatment prep before the patient starts treatment. So in the instance AlignRT is down, we’ll just visually straighten the patient, ensure the correct hand is holding the correct wrist, and then go to our saved table coordinates and then just start our x-rays from there. Our prostate patients, sim once again, they’ll do umbilicus table coordinate at time of sim and they’ll also take pictures. So if vision would be down, we would visually straighten the patient, use that umbilicus table, coordinate for the longitudinal position center, the patient go to the table coordinates, which are once again calculated by the DOSSI and the RTT at time of chart check and pre put in. So we haven’t had any issues with that, but honestly I think since we’ve been up with vision, it’s only been down maybe twice on us and it wasn’t system wide, it was just in one particular room and it, there was an issue with our, our network. Nothing with vision,

Wendy Tisue, MBA, RT(R)(T) (21:58):

Many treatment sites do require multiple CT verification scans to check for anatomy and tumor changes. we do typically do the CT scans, in our room that has a CT on rails, but not all of our rooms have a CT on rails. So, and since we don’t have cone beam CT, we only have our lovely KV imaging, which is another reason for having the one CT on rails. So in the instance that a patient needs to have a vSim, we will do them in in gantry one with the CT on rails, but if the treatment site is too low, we’ll have to take them into one of our sim rooms. Or if a patient also needs a four DV sim, since we don’t do those in the treatment room as as well, so if it’s too low such as a CSI, or something really low on the pelvis, we’ll take them into sim and do the V sims there.

Wendy Tisue, MBA, RT(R)(T) (22:57):

But since we don’t have an AlignRT system in sim, that does make it a little bit more challenging or if the patient, needs to come for a vSIM before the patient starts. But if we do go from treatment room to CT sim, we make sure that the therapist know to add those, setup marks onto the patient. So then that way the sim therapists have a way to align the patients. So Vision RT please make some sort of a SIM system for us for US proton Centers. and then we do have the SOPs, to account for all of the situations if visions would be down.

Speaker 6 (23:37):

So how, how often do you guys do that?

Wendy Tisue, MBA, RT(R)(T) (23:42):

So a lot of our head and neck patients, we have V sims done weekly. but those are typically all done in gantry. One where we have the CT on rails, a lung patient, or like a lower esophagus or liver, something like that where you need that 40 scan. Those will be done in CT sim. And that’s just because our RPM system is set up for treatment mode, not sim mode. we don’t currently use, Vision RT for breath hold or gating just because we do both of those treatments. And I believe at this time vision can only do the DI having RPM that can do both of those breath hold or the gating treatments. That’s why we’re not currently using vision for the breath hold, but if they would get that, we’d switch.

Speaker 2 (24:35):

Once you bring the we the plan to the new evaluation ct that plan by the dosimetry that you’re looking for, how do you go?

Wendy Tisue, MBA, RT(R)(T) (24:51):

We do a replan. So, we don’t have a lot of replan. The plans are nice, they’re robust, but if they ever find that something isn’t within, their parameters or the guidelines and they will do a replan. Just to hit on photon, patients typically don’t have this issue because they’re not doing all the V sims like what we’re doing in protons. But in conclusion, AlignRT has proven to be an invaluable resource in our efforts. There are a few challenges that we have encountered along the way, but they’re all manageable and can be overcome with the right strategies and dedication. The benefits and positive impact of AlignRT far outweigh these challenges, making it a crucial component of our success.