Occipital Mask-Only Treatment: Occipital Mask vs Conventional Mask for Head & Neck Radiotherapy Treatment  

Kyle Noyce (00:04):

We have four TrueBeam’s and we’ve been doing tattooless for a few years now, and head and neck are really the only sites that we’re not using the SGRT for and electrons. So it’s sort of the next step, really was to see what we could do. So these are the masks that we use at the moment. You know, we all know the sort of benefits and negatives. So they, they cause claustrophobia, lots of things about how much claustrophobia they cause when patients have them. So we thought, well, what could we do to help with that? So we’re talking to the people from lots of different vendors and we discussed this with MacroMedics, and they said they were talking about using the DSPS prominent TSPS prominent without the top half basically. So, we thought initially that doesn’t, that seems a bit crazy. But we looked into it a bit further, and they put us in touch with this team from the Netherlands that published this feasibility study who were having really, really good results with it. So we thought, well, we’ll have to do some of our own tests and see how, what we think of it.

Kyle Noyce (01:20):

And we wanted to see basically what it reduces the patient’s anxiety, you know, does the SGRT help with, you know, could it, can it monitor the patient while in there, and does it, does marks actually immobilise them? And just before we started we heard from MacroMedics that the team was also doing very, a very similar thing. And so we got in contact with them and had a good discussion about what they’re doing, and they started just before us. So they had a couple of patients, and they all seemed to be going really well with them as well. And we were sort of looking at what it is that we wanted to get from it. You know, as I said, we check what the patient’s experience is like, want to check how the patient’s experience is like, you know, is it better?

Kyle Noyce (02:10):

Is it the same? You know, in theory, it should be, you think it would be better not have the mask on top, but he thought we would check those sorts of things. Is the patient actually immobilized in the mask? And you know, if they’re not, is the SRT picking up when they, if they do move? So what do we do? So the first thing is that we do daily CCT on all of our head and neck patients. And so we decided, so we’d have a sort of comparison between 25 head and neck in a closed face mask and 25 patients in these occipital masks. And so we used the inter fraction motion using the pre-treatment CBCT, and then we do a day one and weekly post-CBCT as well, CBCT as well to track the

Kyle Noyce (02:59):

intra fraction motion, as well as using the SGRT data for each fraction as well. But that’s on that sort of size. My colleague Toby has done a good job in looking at that, but I haven’t had time to put it all on the screen yet. So we did have specific criteria in which the patients that we selected including because at the moment we don’t have, we don’t position bolus and things like that with the mask with the SRT, sorry. And with our closed patients, close mask patients, we stick the votes to the mask. And so there was sort of an extra solution you’d have to find. And we decided that we would look at this first and then worry about that afterwards. And we gave our patient experience surveys to the patients to sort of get how they felt about to understand how they felt about having the mask done and if it caused them anxiety and things like that.

Kyle Noyce (03:56):

So it’s just a picture of the mask. This is one of my colleagues in it, so, and you can, one of the problems we had with selection was basically, and I think Hannah sort of talked about this roughly, that the frame that the mask sits in is this is the only one, and it’s a specific size. So if the patient is, you know, too, they’re too wide or the head doesn’t fit, or their neck isn’t, you know, if the head, they don’t have a very long neck, so the head sort of fits in, in this part, it can be quite difficult to fit them in the mask. And so there’s quite a few patients, you know, you, we’ve managed to get a good number, but there are patients who just don’t fit in the mask. They also need to be able to lie down flat because you can’t raise, you can’t raise the, the frame. So if they can’t lie down flat, they can’t go in it. And also just to exclude anybody who had any like conditions that made them not be able to stay still, like Parkinson’s or anything like that.

Kyle Noyce (04:51):

So initially, these are sort of the ROIs that we started using, have one for the face for the treatment and then one for the shoulder position for setup. But we sort of found that it can be quite difficult with the shoulder position to understand what the TLDs are telling you because, you know, if one of the shoulders up and one of the shoulders is down it, it sort of, you can’t, it’s difficult to visualize what that means from just the numbers. So we started using the Postural video quite a lot as well to really position the shoulders because it is so much, it’s a lot easier to sort of visualize where the shoulders need to be using the posterior video. And this is what we sort of found from it. So in terms of patient experience, this is where the first 14 patients are, because the other ones are either still on treatment or, like in planning 71% of them had no anxiety making the masks at all, which is obviously very beneficial.

Kyle Noyce (05:56):

And 90% of them didn’t have any claustrophobia about having the mask made and just had quite a positive experience. I mean, a lot of them would say that they were quite worried about having the mask done. And when we gave them this option, they were quite they were very happy to do it. The way that we sort of selected the, the patients was very much that we gave them the option, so you sort of made sure that they fit in the criteria that we want. And then we gave them the option of having one or the other because you don’t want to force anatomy they didn’t want. And then we have the inter fractional motion results for on here. So as you can see, they’re very positive. They’re very, very similar and not really clinically different.

Kyle Noyce (06:50):

Obviously, this is the setup you know, how much the patient, how much, how a shift you’ve had to do once you set the patient up. So it’s important, but it’s not; I think the intra-fractional motion is just where you want to make sure the patient isn’t moving during treatment. So this is, this is always positive for us. This is the beginning. And then for the intra-fractional motion, it’s also, you know, it is not clinically any different, not clinically worse if anything, for the translational shifts, but it was slightly better. And for the rotational, it was slightly worse. But well within what you’re sort of happy to accept. And we also have some data from Jonathan and their first, I think it was nine patients, I think for this one.

Kyle Noyce (07:46):

And they show very, very similar things where, you know, it’s, it’s all well within, you know, what you, what you would accept for our, our you know, close these patients compared to these patients. So, we were very, very happy with that. The main limitations we found with them were basically the setup times we defined, which were longer, and it was, it varied quite a lot depending on the patient or the experience of the team that was doing it. If the team’s got a lot of experience doing it, it can, we can do it quite quickly. And if you know, for whatever reason, what we tried to do is we tried to keep all these patients on the same machine so that the same team could, you know, gain experience with it and then they would have, but you know, it’s like things have to get mixed around every now and then.

Kyle Noyce (08:34):

And if you end up having somebody who isn’t so experienced with it can be a bit more challenging for, for, for the setup for them. And, you know, you get, you have to provide a lot of additional training. I mean, we spent quite a long time at the beginning before we started having maced come down and do some training with people, and then we did some in-house training just to get everybody prepared. But like I say, you, you trained people at the beginning who, and then they, they use the system, but if somebody was trained at the beginning, but they haven’t used it in a little while and then they come back to using it once they, you know, there’s, things get mixed around, it can be a little bit more challenging, especially when specific, there are specific patients who need like, specific things you need doing to them that, you know, one of their, like one of their shoulders needs to be a little bit higher than the other one, or these sorts of little adjustments that if you are used to that patient that you know what to do.

Kyle Noyce (09:28):

But if you’re not used to it, then it can be a little bit more challenging. And the other thing is, they do cost more. So you know, unfortunately, that is the reality of these things, that they are significantly more expensive than our closed face masks. Even in the open face ones that we are, we’re sort of looking at them in the next few weeks. So, you know, you have to sort of take that into account when, if we can, if you can, you know, get that past the people above you that you can afford to pay the extra cost and what sort of benefit it brings for that additional cost. And you know, we did have the other thing as you consider is we have had like a, we have selected these patients.

Kyle Noyce (10:14):

So in theory these are sort of, you know, it’s relatively small, only 25 patients, and this data is only for the first 15 as well. And, you know, these patients have been selected by us as, you know, they’re not, they’re the patients who wanted to do it and they’re not you know, patients who may, may get more benefit out of it or more may have more issues, we might have, you know, decided not to do because of they had lots of movement. So we decided we had lots of movement when we were checking them at CT, so we decided, oh, we’re not going to put them in it. So it makes us look better when reality is, is that it might not be suitable for all patients. And so you, it’s not like from my point of view, it’s not a solution for all patients.

Kyle Noyce (11:00):

It’s just, it’s an option that we can use for patients who really benefit from it or who, you know, want to use it. But as I said, there are limitations about being able to fit in the shell and lie down and that sort of thing. But like I say, all the questionnaires were very positive. Every, all, all the patients, you know, on day one, the patients would come around, and they’d say, oh, I’m so glad I’m not having, having this mask. And the interaction inter and intra-fraction motion has all been very positive. I know it’s all been well within what we would accept for our close face mask patients. And this is some of the quotes from some of the patients that wrote in their little surveys and what they wrote about their experience having the masks made.

Kyle Noyce (11:48):

And like I said, they’re all very positive. Well, they all feel secure or they, they were, they were worried about being claustrophobic and about having their mask made. And one of the patients, this one had a very was very swollen face because they had some like surgery on their face. And so their lips and their face were all very, very swollen. And we initially, we were worried about whether or not they would be able to how the SR t would track them as they, you know, as they go through treatment, because of the swelling or if they’re swollen, it’s CT and then they, as the swelling reduces. But he was actually really good, and they didn’t see that the SRT worked really well with him, and what we’re sort of hoping to sort of help other places that can, who are thinking about doing the same thing, and you know, look at what other patients should be able to do it.

Kyle Noyce (12:42):

You know, we look at solutions for our bolus, but we don’t have a solution for the bolus. So what we can introduce for those patients, and if we can do it for, as you say, you’ve seen you doing it for the, so lung SAS because of the shoulder position, like those sorts of things, and you know, and, and like brains or palliative patients and things like that. But overall, I think in terms of what our data has shown, it’s all been very positive. I think it’s more about ensuring that the staff are happy with what they need to do when things ne aren’t necessarily going right or how to set the patients up and make sure those patients have the best sort of position to be in. This is just some thanks to the team that have been really, really helpful. I can do it without them. And in terms of the SGRT data, like the intra-fractional data I call Toby, who’s over there, has done lots of work in looking at how the how many times the patient moved out of position, what the, you know, what their position was for each fraction and overall. So if anybody’s got any questions about all those sorts of things, too, I’d be very happy to answer those sorts of things.