Using SGRT and Faceless Masks to Improve Patient Experience While Maintaining Accuracy

Hannah Dyer (00:04):

So I’m Hannah Dyer. I’ve been working up in Raigmore for the last four years, and we have had AlignRT for a number of years. I’m just going to go through our process of how we’ve introduced open face masks to our head and neck patients. So yeah, that’s just our, what I’m covering today. So we only have two linear accelerators, so we’re a very small department, but in that way, we are like a good team working together. So we can make improvements quite rapidly. We’ve got race station planning moving to rake here instead of area in the near future. And we use AlignRT SimRT and MapRT within our patient workflow. So this is just showing the timeline of when we have had a MapRT and AlignRT come into the department.

Hannah Dyer (00:57):

As you can see, it has been quite A long journey, but now we are treating all of our patients tattooless, and anybody who requires a mask will have an open face mask. So you know, we are making improvements towards improving our patient experience. I started working in Raigmore around 2021. So at that point, when we started doing all of our pelvic patients without tattoos, and we’ve moved totally tattooless as I said there. So in 2022 we started trialing doing shoulder list masks because we could see from our images and from our EPI results that patients, even though they were immobilized using a five point mask as is standard and you know, we’ve got all the, the, there’s lots of products out there we could see that patients’ shoulders were had still got a lot of room for movement.

Hannah Dyer (01:52):

And if you’re talking about patients who are coming in, they’re losing weight. We all know that they’ve got more room there for movement. So then we’re getting these like big gaps, as you can see in those images there. So we can be all of our head and necks I should say. So it is evident to us when there are gaps and when there aren’t gaps, and we take our EPIs using the MV panel so that we have that data analysis so we can see the differences in our dose distributions. So at that point, we decided to go shoulderless and we’re, and we decided to use two different ROIs at that point. So, using our face ROI to start with and our shoulders, so that we’re monitoring what we can see, what we need to be monitoring. I’ll talk a wee bit more about how this has kind of changed since we’ve moved on a wee bit, but this is what was, was standard for us at that point. And we do also have Postural Video on AlignRT. So what we do to get the patient set up is actually manoeuvre the patient without their mask on to start off with, using the Postural Video and the delta positions, and then put their mask on top. So even the patients who’ve had closed face masks, we’re still using SGRT to enable setup in that way.

Hannah Dyer (03:10):

So then we started using our faceless LTT masks, trailed with all our palliative patients around the same time. These studies I’m talking about have been very small, sort of pilots within the department. So we, because these were palliative patients and at the time it was standard to just do a lateral MV image because they were mostly whole brain patients, some of them did have KV pair images. So we compared the imaging shifts that we had on those masks to those who had had full face masks retrospectively. And this covered 24 patients. So obviously, we are lacking in the AP image analysis there because of the images that we had taken. But we found, as you can see, there are no significant differences between the shifts that we required for the faceless masks and for the closed face masks. You can see there’s no, no significant difference, but also no clinical difference if you’re looking at the size of those shifts.

Hannah Dyer (04:09):

So that’s the root mean square that we took for them so that it’s not a means, it’s not a in itself, out they’re sort of true shift. You can see that there’s not really any difference between the two systems. So we were quite happy that those Orfit masks were doing the job that we needed them to do. So, moving on from there, we decided that we would trial a different type of mask that we use for our head and neck patients and our radical ones. So we used the faceless DSPS masks. So previously we’d used the full face DSPS and then we trialed that in 2004. And all of these patients either had KV imaging or they had cone beams, depending on what their dose in fractionation had been. All of our palliative patients would’ve just had KV paired imaging, and if there was a slightly higher dose, would’ve had cone beam as well.

Hannah Dyer (05:00):

And you can see we’ve compared 20 patients for the full face mask and the faceless mask, and given us imaging shifts in three degrees which is important because anything that we’re cone beam, we would actually match in a six degree. Because we match all of our cone beam in six degrees, because we only have the two couches, and both our machines are enabled with that. But I retrospectively rematched them in three degrees so that the KV and cone beam information was compatible there. And again, you can see on the vertical and the horizontal, there is no significant difference between them. So that is fantastic, really. And then, as you can see at the bottom, our lateral shifts were actually smaller, like significantly smaller. Statistically, not probably clinically, as you can see it’s not a whole lot smaller but statistically smaller on the lateral. So we are going to get a better visualization of the patient’s face and

Hannah Dyer (05:56):

Position using SGRT and an open face mask so we can see that their face isn’t in the right place. So that is where we’ve gone from there. So, going on from that, all of our palliative patients now are treated on the LTT masks, open face masks. It makes it easier for trolley transfers and things, whereas the DSPS has got that extra frame, which makes that a little bit more difficult. Our head and neck patients at the moment are going to be using the DSPS prominent mask. So we were one of the first departments in Britain to get this, and we’ve done a lot of work with it. So as you can see out in the, the vendors outside, it’s got a dorsal shell. So that’s going to provide the patient with support of their shoulders. And what we are going to be doing is using it for, well we have been using it for all of our head and neck patients that fit into it.

Hannah Dyer (06:53):

So there are some discrepancies about whether or not the patient’s got long enough necks to fit into the mask and things. But we’ve managed to fit most of our patients into it, and we’ve still got a lot of results there to publish, which I’m sure you’ll see soon. We are moving on with that now to treat them all faceless because we’re quite happy with the mobilization system. We know that the patients aren’t able to move and that is what we’re hoping to do for all of our radical patients. Now I’ve got so as I was saying about the monitoring with a line, what we are using now is actually just a face-only ROI instead of having one on the shoulders. And as you can see, we did some testing on some staff. So in this example, the one on the left-hand side, the staff member was asked to move their head like to nod their chin up or down and you can see that that’s giving you an aligned tolerance on the deltas is out of tolerance, whereas the head and shoulders one isn’t.

Hannah Dyer (07:58):

So if you were using that for your beam monitoring, that beam would not automatically turn off. So we have decided that moving forward, it’s best just to have a small ROI that’s more accurate on the area that we’re actually wanting to treat. And if you imagine if someone nodding their head up and down, that’s going to change your neck flexion and everything. So that’s what we’re looking at and we can use a Postural Video to check their shoulder position instead. These are just more examples, so slightly smaller ROIs being used there. And again, the same head movement on the right-hand side there is coming out of tolerance and then the one on the left is only very, very slightly out of tolerance. So you could convince yourself one way or another whether or not that’s due what we need it to do.

Hannah Dyer (08:44):

And this is just showing, I don’t really know if you can see on this, but here’s how different the position is there, but it’s only really showing you a centimeter different because it’s only on one shoulder. So all of those shifts have kind of been evened out across that large area. So this is why we’re focusing purely on the face. I’m just going to go through a couple of case studies. This one is next lady is a brain patient, but it’s the same principles that we’re using. So she had steroid-induced swelling and we delivered five fractions, and then this lady was no longer able to have her mask put in. We added shims as a standard, but we couldn’t go ahead with her treatment on that day. She was sent back up to the ward. At that point, we decided that we would cut the front of her mask out and enable beam control on AlignRT so that we could deliver her treatment effectively. She didn’t need to have any more gaps in her treatment, and as you can see on there, this is the area of swelling. So there’s no way we were going to be able to get a full face mask on that poor lady. So that, that is how we proceeded with her.

Hannah Dyer (09:54):

We are trialing sort of using frontless masks for different indications at the moment. Our arms down sabr patients, lung sabr patients and in extenuating circumstances, so like that laid facial trauma and patient anxiety. And that was just to show you that we are using beam control on all of these patients as well. So if they were to move the machine automatically beams off there. This next man is our most recent example. You can see he is a radical RT and we, he had no history of claustrophobia or anxiety, but as you can see in his images, not great shoulder position. Even using this is using a prominent shell here. So you can see the big frame, but the man was clearly very uncomfortable. It showed up in our EPIDs that he was not in the right position. We can do a root cone beam; there’s something not quite right there.

Hannah Dyer (10:52):

As we get into it, we realize that this man is actually horribly claustrophobic and had had a horrible experience as a child and had therefore internalized all of this, putting a mask on, had brought up all of this trauma that this man had. So we had to figure out a way of going forward with his treatment. So we decided that he was an ideal candidate. He was very sensible that what we would do is actually treat him without the front of his mask at all, just using the back half of his prominent shell. And as you can see, our imaging is much better. There’s some movement here as you can see, but comparing those two fractions, it’s like night and day. We did an interview with the patient afterwards, and I’ve just got a couple of quotes from him as to like why we’re doing this, why we want to be improving our patient experience.

Hannah Dyer (11:47):

You know, these patients come to us who may or may not have anxiety. We don’t know. And this man didn’t know, his wife didn’t know they’d been married for 40 years. She didn’t know that he was claustrophobic, and you know, and this is what we did to him, brought up all of these experiences he had to be medicated. These are things that we don’t want to be doing to our patients. So we have just a couple of things, just so you know, he hated it. The anxiety, the relief that he had afterwards. And like when we were doing this interview, it was very moving actually, just to hear what he was saying because he’d had such a horrible experience and we hadn’t realized really, you know, we, we were all like, oh the patients are a bit anxious to get through it, this man wouldn’t have got through it at all. So, you know, it’s a revelation, and this is what we are going to be aiming towards doing for the rest of our patients now is to move forward with open face masks primarily but using the front list where we can. So I just want to say a massive thank you to everybody at Raigmore as well as everyone at Vision RT that’s been helping us along with it. Thanks.