Adi Robinson
Senior Medical Physicist, AdventHealth Celebration, Florida, USA

Video Transcript

Adi Robinson, Senior Medical Physicist (00:04):

These are my disclosures and what we do you’ve already seen what AdventHealth looks like just as a different map that Mike uses. This is where Mike lives. This is where I live, you know, Mickey runs the state. So but important note about AdventHealth is that we really focus on innovation, safety and the patient experience. We put that as our number one goal. And part of what I’m going to talk about is carving that path using AlignRT. First of all, you can have biometric facial recognition to eliminate your timeout if you purchase the patient AlignRT to really, really emphasize these steps. So, for those who don’t know what SGRT is, we register a time 3D surface of a patient to a reference surface comes from CT. We use camera projections to generate that surface in real time, and then compare that to the patient’s positioning on our reference dataset.

Adi Robinson, Senior Medical Physicist (01:06):

By doing so very, very quickly, we still get sub-millimetre accuracy as Mike detailed in his commissioning talk. And, and that’s, it’s pretty amazing. So with the out of the box AlignRT you get the following: You get enhanced patient set up add-on where you can just capture the patient’s face on day one and that kind of interlocks and gives you that no need to ask for their birth date and name and all that social security stuff every day before you treat them. You get Postural Video, which is this, this view where it’s kind of an outline of the patient. So you can set up the patient based on your six degrees of motions, your real-time deltas, which are based on the ROI that you drew.

Adi Robinson, Senior Medical Physicist (02:09):

But you also have this full body view to tweak the positioning of the arms, the legs, the knees, the abdomen, the arch of the back, whatever you need to do in order to kind of perfect the setup. And by doing so, you basically eliminate tattoos. You’ll hear about today and tomorrow about all these facilities that are tattoo and markerless. They don’t use that anymore in their facilities because they set up to the surface, not those three random dots you put on the patient. Adaptive monitoring deformation view, which you’ll see here, kind of compares how the surface looks today versus how the surface looked at CT. And it gives you some sort of metric, so you can see high and low spots. You can see if the patient has swelling or then doesn’t have swelling anymore, if they gained weight, lost weight, anything in that surface changed.

Adi Robinson, Senior Medical Physicist (03:00):

It also helps you optimize your ROI. So if you see a lot of red or blue areas in your ROI and the patient’s supposed to be DIBH or free breathing or whatnot, you can kind of customize your ROI for best utilization for that patient. So I think it’s a very underutilized tool, but it’s, it’s, it’s very, very, very powerful. And you have motion management. So you can either use the respiratory gating module right here if you want to do amplitude or face-based treatments. But if you’re just doing DIBH, you can use the regular-time motion with beam hold, and you can do DIBH. So all of that is AlignRT out the box. Probably some of you are familiar with it but it also comes with some challenges. It does still provide precise setup and monitoring.

Adi Robinson, Senior Medical Physicist (03:52):

However, as we just saw, the ROI can be challenging. It is manually created and is very, very subjective. Some therapists like it one way, some therapists like it the other way, there’s no kind of uniformity across the board. Some have more experience, some have less, some spent 10 minutes drawing it, some spin, three seconds drawing it. So there’s no consistency and that leads to trouble down the road when the patient actually shows up for treatment documentation. So if you need to prove that you actually treated that patient, that fraction with AlignRT and you can have continuous, you have a manual process of doing so. So you have to generate the report at the end of the fraction, import it outside of the AlignRT system and into your record and verify system while the next patient waits for you to finish doing that. So it is a kind of clunky workflow, and if you have to document and if you have to do it for billing or for audits or whatnot, it takes time and it’s not so simple.

Adi Robinson, Senior Medical Physicist (04:55):

And then you have limited plan or dose visualization during the setup of the patient. So before you even turn the beam on, you kind of want to make sure that you’re setting them up correctly. And an overlay of what the plan is going to look like would be very, very helpful. So, lo and behold there is some AlignRT innovations that address those workflow limitations. So with Beam Guide, we have a visual overlay of the patient’s plan over Postural Video with the OIS reports, we have an automatic documentation module, and then Auto ROI gives us a fast and accurate auto ROI generation. So let’s start in the beginning when we’re going to, you know, we just prepared the patient and we’re going to draw the ROI, you know, normally the ROI for those who don’t know the region of interest is that area on the body of the patient’s body that the system’s going to compare current versus reference positioning.

Adi Robinson, Senior Medical Physicist (05:51):

So that’s where the three six degrees of real time deltas come from. And as emphasized earlier, and you’re going to hear that a lot today, a really well-defined ROI ensures that AlignRT can accurately track the patient’s positioning. If you have a garbage ROI, it’s going to be really, really bad RTDs and really, really bad setup. So you’re setting the tone here for the patient’s treatment. So with auto ROI per protocol, it will give you about three to five options of what the ROI should look like, and you can preview those on your actual patient and then decide which one works best for you. We’ve, throughout our testings, that about 90% of ROIs are clinically acceptable with almost no changes to them. But the module does give you the option to edit it. So you can, if you see something that you like but you want to tweak it a little bit, you can still edit to it.

Adi Robinson, Senior Medical Physicist (06:48):

If you want to start over, it can erase the whole thing and kind of try again. It does introduce consistency and reduces creation time. So let’s look at a few examples. So we treat a lot of breast patients in our clinic. So here’s an example of our right and left breast. You have the autogenerated ROI here, this is the manually drawn ROI that we use clinically. This is the overly difference. And you can see it’s about 90% similar ROI. Now what we did is we set up the patient in a few, a few fractions using the auto ROI made sure that all the deltas are happening right before treatment. We flipped to the manual just to see how the deltas are changing, if we can just continue treating. And we saw no difference with, with breast plan.

Adi Robinson, Senior Medical Physicist (07:35):

So that gave us the confidence that the auto ROI is is is very, very useful. With brains and an open face mask, it’s a little bit more challenging because the ROI, depending on how you make your mask, you know, how lateral do you go and, and all of that. But with all that said, again, looking at two cases here we are a lot more generous in how we we do, at least from this view, but it’s still about, you know, 85% similar. And again, it give us good clinical results. So, you know, these brain ones might need a little bit more tweaking, but it’s still a five second generation time versus, I don’t know, a minute or two. So I don’t know, count that counts with something. Pelvises are a little bit more complex because depending on your clinical needs some, in some cases patients, we use this band over the pelvis and some of them we don’t.

Adi Robinson, Senior Medical Physicist (08:33):

Some of them we just focus on the thighs. So that’s kind of a selection that you have to make clinically, but both Auto ROI generation generated ROI’s have either just thighs only or thighs with band. So you kinda have to decide what works for you. And this shown good success for us. So kind of to summarize that we are able to implement it across broad treatment sites. So it currently, you have auto ROI protocols for breast DIBH free breathing chest, abdomen, and pelvis. They’re all headfirst, supine but I’m guessing more and more ROIs will come as the as more implementation of this module will happen. And, but what we’re really excited about is this consistency, consistency in standardization. Now we have a minimally good starting block for ROI creation.

Adi Robinson, Senior Medical Physicist (09:37):

So I can bring a therapist straight of out school, he’s never seen SGRT in their life and I can explain this better to them than the old flip book that sometimes can be confusing. So we have a minimum standard that we like and then we can just adjust it from there. We don’t care that much about time savings. We have an offline, you know, workstation that we can use not during treatment, but it’s the quality of the ROIs that we want to elevate. And now we’re start, our starting point is much higher than what it was before. So that is kind of what we wanted for, we’re looking for. So beam guide once the ROI is generated, we’re ready for treatment of the patient. So we need to set them up. And what now the add-ons to Postural Video is twofold.

Adi Robinson, Senior Medical Physicist (10:21):

We have a, a plan outline which just shows the outline of the patient here in white on top of the postural video that you see it in, in purple. And we also have the, the planned projection. So this has got an active projection of where the, the beam is going to go. So kind of imagine of where the dose is going to be deposited, kind of thought. And those, they can exist together or you can turn one of them off, whatever is confusing. But now you can set up the patient based on where the beam is going to go. So, being a physicist, we like to validate things. So before we start using it, I kind of generated plans with certain shapes and I wanted to see how well can beam guide can reproduce these shapes. You know, I made classic shapes, but then I started thinking, we need to make a mistake.

Adi Robinson, Senior Medical Physicist (11:13):

Will it catch a planning mistake? So I created a circle, a bad circle with a leaf pulled out and a leaf pulled in just to see how it goes. We have the luxury in my clinic that we have dose RT as well. So dose rt as you’ll see today gives you kind of a, a verification of what the dose, what the, what the dose you delivered. Kind of it’s an end of treatment dose visualization during the end. So I can actually use Beam Guide to validate DoseRT and DoseRT to validate Beam Guide. So it’s kind of a, a cross-contamination thing. So here is, oh, video’s working good. So here’s me looking at the field and beam guide postural video view. So I’m kind of loading up the triangle and the diamond and there’s the L shape

Adi Robinson, Senior Medical Physicist (12:09):

And the circle which all look good. And then I want to see what the bad circle look like because that’s the important part. And it does pick up that there is an MLC leaf out of the way in and out of the way out. And I can turn off the projection if I wanted to just to kind of focus on the, on the field light, but this is what I wanted to see. I didn’t want see something that kind of ignores that. So that’s good. So if the therapists are setting up the patient and they see something that is unexpected before they even beam on, before they did anything, that is kind of a hard stop for us. And then they can come to physics and say, Hey, I expected the plan overlay to kind of be on top of the breast, but I’m seeing it on her chin or something.

Adi Robinson, Senior Medical Physicist (12:50):

We need to kind of look at it, and then we can figure out if it’s a setup issue or a plan issue. But we haven’t harmed a patient yet. We haven’t delivered anything. So that is a very important tool. So here’s a bit of a DoseRT versus Beam Guide kind of comp comparison where this is the, I delivered all these plans and this is what it looks like. This is a cumulative fraction image. So you can see the triangle correlate to the triangle. The diamond correlate to the diamond, the LS shape correlates to the L shape. And this is the two circles, the good circle and the bad circle. And the error is visible in both, which is good. That means you could see it either before you set up the patient or after you set up the patient, but you want to see it before you set up the patient especially if it’s a planning error.

Adi Robinson, Senior Medical Physicist (13:42):

So here’s some real time, real live cases that we’ve used it for. You can see this is a VMAT case where we just treated an arc to arc VMAT. I’m expected to see a band across the patient’s pelvis, and that’s what I’m seeing. This is a prone breast case. I know you guys don’t treat pros a lot, but this is kind of one of more interesting case that I’ve found because we set up this patient Postural Video, looks awesome, rt, the six degrees, deltas look awesome, everything’s in the green, everything’s good. But this little sliver of breast is not covered by Beam G

uide, which means it’s going to get underdosed. So we had to fix her rotation. There was something, there was an issue there. And once we tilted her a little bit, her entire breast was in view and then we delivered the fraction correctly.

Adi Robinson, Senior Medical Physicist (14:38):

So this is something that Postural Video, none of the features of AlignRT right now was able to catch, but beam guide and that raised our confidence in the system, you know, through the roof. Here’s a supine DIBH breast, and again you can see in three different views how the breast looks like and then how it was delivered. And the shapes look the same. And that’s kind of what I’m looking for here. That the pretreatment shape looks the same as the post-treatment shape looks the same as in the treatment plan, and that’s ideal for me. Here is kind of a challenge that we like to do. Sometimes we get stuff to test and I do a blind challenge for the therapist where I get a piece of equipment and I kind of tell them to test it and I want them to the real reaction to them.

Adi Robinson, Senior Medical Physicist (15:26):

So we got this clear bolus to test and I figured this super clave and right breast, left breast patient would be the best candidate for it. Now we do it mono iso ally, but we don’t bolus the super clave. And I kind of wanted to see if they’re able to use Beam Guide to set up that bolus. So in Beam Guide, you can select which field you want project. So you can do all fields, you can do just the super clave, or you can do just the, the breast. So the whole idea was put, turn on the super clave, only put in the bolus, make sure the super clave is not bolus, then turn off the, the, the left breast, make sure that it’s all in the bolus, then turn all of them, see how it looks and then treat. And this is the resulting treatment, but it doesn’t really tell us much.

Adi Robinson, Senior Medical Physicist (16:11):

This is pre-bolus setup, this is post-bolus setup. You can see how clear and shiny the bolus is. So if we look at the actual delivery of the beam, this is the Taren cough signal coming from DoseRT. And you can see we’re treating the super clave. It’s hard to see, but this is the outline of the bolus. So they set up the bolus perfectly without seeing that bolus before. We saw almost not no beam guide experience at all. And they did right off the bat. Perfect. So that’s how easy it is to use Beam Guide in setup. And I was very impressed that they were able to do that. So kind of talking about Beam Guide in general it’s easy to inter if you use Postural Video, it’s easy to integrate in all of your workflows right away.

Adi Robinson, Senior Medical Physicist (16:57):

And it’s super, super, super helpful if you have any accessories or kind of a budding fields and you got to have to worry about a gap or an overlap or something like that. It gives you immediate visual confirmation of your beam entry and exit, which is super, super, super useful. And you know, our, I quoting my therapist here, they said it’s a must have. And they love seeing the plan at set up. So it’s, it’s, it’s a very, very valuable tool. So now once we treated the patient, we need to document that we treated the patient. And this is where the OIS reporting module comes into play. We have Aria, but it also works on Mosaic. So, but this is an ARIA snapshot. This is the treatment basically with CBCT, the four arcs. And then now the align RT reports are going to pop in at the end automatically.

Adi Robinson, Senior Medical Physicist (17:48):

You don’t have to export, import anything. It just set up for once and it’s going to do it forever. If you click on the screenshot, it shows you the, the screenshot that it takes at the last second of treatment. So you can prove that everything was within tolerance. And if you want to see the full report, it’s right here. It has the patient’s name, MRN, how long was he monitored for, you know, you can have the delta graphs of how much he deviated and all that stuff. And all of this is available for the physician to approve as they’re approving their IGRT images. If you’ve taken them that day, they can approve the SGRT images all at the same time. So that’s really, really, if you bill for it or if you need any kind of documentation for audits, you can see that the physician reviewed both IGRT and SGRT at the same time before the next fraction it was approved.

Adi Robinson, Senior Medical Physicist (18:39):

And here’s the documentation that we actually did that. So, all in all, about the new modules, I think the integration of the new modules represents a significant advancement in AlignRT. Though the tools in really, really enhance treatment verification, documentation and automation and really, really improves the position safety and efficiency of our workflows. And I think I would recommend you guys using it because it really, really makes the clinic life a lot more efficient and simpler and just, just always going to be something more. So it really, really makes the complex a lot easier. So with that, thank you to Mike. And yeah, this is me on a normal day. So thank you.

Dawid Bodusz, PhD, RTT
Head of RTTs Team, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland

Video Transcript

Dawid Bodusz (00:04):

So good morning, ladies and gentlemen, or hello everyone. It’s a great honour and pleasure for me to be here and to be with you after this amazing evening as well. And I would like to take you on a little journey through our experience. You can see on this slide open face masks and surface-gated radiation therapies. So, AlignRT is used in patients undergoing stereotactic radiotherapy for head and neck regions. As we all know, probably all and probably know in contemporary radiotherapy, especially in stereotactic radiotherapy, we live in the world of strict precision. So we live in a world with millimeters and degrees, and sometimes it looks like we talk about our patients, about problems, about our setup accuracy every time. And do not speak about, for example, holiday plans.

Dawid Bodusz (01:14):

But I hope it’s not true. So today I want to show you how we in our department try to keep our submillimetric precision under control, and at the same time keep our patients a little bit more comfortable and a little bit less claustrophobic. So to do that, I need a plan. I hope I have it today for this presentation. So I will try to introduce my own radiotherapy department, explain how and why we moved towards open face mask and surface guided radiation therapy. Show you some data about setup accuracy, infractional motion few words about bite blocks influence of bite blocks on this accuracy. And finally, I will try to translate all information into clinical conclusions. So let me start with a little bit of context, where all things are happening.

Dawid Bodusz (02:28):

So here you can see my radiotherapy department and part of my hospital. It’s a comprehensive cancer centre, and you should know that we have separate radiotherapy departments, separate BRCA therapy department, and separate treatment planning department. It’s not standard even in Poland, but we have separate this ra treatment planning department as well. As you can see, we are quite a busy department radiotherapy department, because at this moment we have 11 linear accelerators. Eight of them are C series of standard Linacs, seven TrueBeam, one Edge, and six of them have AlignRT systems, two of them do not. Maybe in the near future, I hope that in the next year, we can buy a new treatment machine. So we treat we buy it with AlignRT, of course, because it’s a standard for us.

Dawid Bodusz (03:34):

So we have KV imaging one. So it’s a CyberKnife with MultiLeaf Collimator and one, it does some solution for native radiotherapy. We started a native radiotherapy last year in April 2024, not two, but free operative units. We have actually, at the moment, one superficial hyperthermia unit. In the near future, we want to buy a deep hyperthermia with MRI, I hope it will be with MRI, to check the temperature inside the patient as well. So per year in total, we treat about seven thousand patients. And daily, it’s about 300 free 15, 315 sometimes. And with such a workload, if we change something in our procedures like immobilization systems, like imaging procedures, it cannot be only beautiful on paper, but it has to work on a scale. So it should be safe, it should be reputable, and it cannot destroy our daily schedule.

Dawid Bodusz (04:57):

So if we talk about open face mask and we talk about SGRT, we do not talk about a few or several patients per year, but we talk about workflow. It must fit into the large real-life department. And of course, these all things are managed by multi-disciplinary teams. As you can see, we have a lot of RTTs in our treatment machines. 34 radiation on cardiologist, six nurses. And you can see here on the slide radiation physics medical physicists, but they exist, but in a different department, of course. So treatment planning department and a special department for QA and measurements. Okay. This is a slide about our environment because we try to have a quite nice and friendly environment for our patients and our staff. So we try to have some wallpaper, some nice slings, and you can see here our auto therapy unit with modern lines.

Dawid Bodusz (06:08):

So if we have a lot of problems, a lot of patients, and we need to take a deep breath, for example, we can go to the tunnel therapy turn, switch on the lights, and have fun. Of course you can, you can we, we have here the video without sounds. Okay. So how can even consider changing our standard approach because it worked. So, there are two simple reasons. First, it was that we implemented it into our clinical practice edge. So it was our first machine with align RT system. And with this machine and with this system, we took a new immobilization system for stereotactic. Radiotherapy Edge is a machine dedicated especially to radiosurgery or stereotactic radiotherapy. And the second full face thermoplastic masks are a very good tool to manage the motion, but have some jaw backs, for example, limited visibility of the patients.

Dawid Bodusz (07:26):

And for example, sometimes more anxiety and reduce camera based monitoring. So we can use SGRT, of course. So that’s why we started with open face mask, and we had free objectives to this study. Why? Because we tried to answer the questions, can we be as accurate as in the standard procedure with a face mask or even better, and at the same time, make our treatment more comfortable, so patients are friendly. So we had three main objectives. First, to evaluate positioning precision with an open face mask and SGRT. The second assess the patient’s ability during treatment, values vary and to determine the optimal routine. And because we all like some details, we checked the influence of bite blocks in our patients as well. And it was very important for us because new immobilization system we use, has the possibility to use two different kinds of thermoplastic masks.

Dawid Bodusz (08:44):

I will show you it a little bit later. So we included three groups of patients. The first group, it was Qfix group, so it was an original kind of open face mask for this system. We use it on 51 patients with Qfix open face mask, 100 patients with a Klarity open face mask. It’s compatible with our IM immobilization system. Additionally, we have something like a control group, because it was 42 patients with a closed face or fit mask, but treated in a standard fractionation. So standard radiotherapy. We had about 100 for 1,400 measurements. So what about our treatment, daily treatment machine workload for this group of patients treated with stereotactic radiotherapy, we set up the patients using, of course SGRT system. So we had not we have not here any markers on the face mask.

Dawid Bodusz (10:01):

We just used the SGRT. So the next step was CBCT verification to get some information about our accuracy and inaccuracy, of course, to verify the position to move the table to the correct position and to assess the accuracy of our systems. And the last step was treatment delivery, of course, with monitoring SGRT monitoring during the one session of radiotherapy. We had 200 measurements for Qfix group of patients about 400 measurements for Klarity patients, and about 700 measurements for Orfit. So full phase mask radiotherapy. Here you have information, same eye as I told you. And here you can see our immobilization system. We use it for this group of patients. So for Qfix and Klarity, what is very important that for this encompass, SRS imobilization system, we can use an original open face mask, but we can use a Klarity mask as well.

Dawid Bodusz (11:22):

Both of them are compatible with this system. Of course, you can see that this symbolization system provides rigid fixation to minimize movement in all three special dimensions, and so on and so on. Here you can see the original open face mask with bite blocks. It looks like this one. Here you can see the clarity mask with some differences. So it’s similar, but for example, bite blocks look like a different fig in this way. Of course, we did some statistical analysis, descriptive statistics on non-parametric methods due to the fact that most variables deviate from distribution. And here you can see our results for this system. So, first of all, it’s not surprising that Orfit systems or standard fractionation, standard full face mask show us that results are larger than for the SRS system.

Dawid Bodusz (12:32):

So both systems Qfix and Klarity. And these differences are for all translations and all rotations, excluding vertical. Because vertically, we saw that there are a little bit better results for Orfit. So, for full face mask, we do not know why. What’s the reason? But probably we found the last few months that we had some problems with. We’ve outlined our skin and our body. There are some differences between skin and body, and we, if we use some of them, we can see some oh 0.5 millimeters differences between our results in SGRT system if we check Qfix and Klarity, which is very important for us? Can we use Qfix or Klarity or not? We do not see any big difference. And what is very important, our inaccuracy is less than three millimetres, even in vertical translation, and for longitudinal and lateral translation was about zero millimetres.

Dawid Bodusz (13:56):

So we are very, very precise in these translations and for rotation, all are below one degree. So it looks like we are quite precise. There are some statistical differences between system, between Orfit of course, and Qfix and clarity system. It’s not surprising. And if we compare both group of system for full face mask, we see the lower vertical translation, but it’s not bigger than oh 0.5 millimeter larger longitudinal translation, greater rotational division and higher jaw dispersion for Qfix and Klarity. So both together, higher vertical translation, but smaller longitudinal translation, lesser rotational deviation and lower jaw dispersion. And there are no significant differences between QFI and clarity in the vertical or lateral axis. What is very important for us is a few words about the influence of bite blocks. Well, if we use it for a subgroup for Qfix system and for Klarity system, there is no measurable impact on translational accuracy across all access for both systems, for Qfix and clarity.

Dawid Bodusz (15:30):

But we found some significant improvement in the jaw if we think about Qfix system and some reduction in pitch error in Klarity system. So here you can see the same results in some images. And you can see that if we think about translational, there are no differences between bite blocks and with group without bite blocks and some differences if we think about cfi system, we found some differences in rotation and for clarity in a pitch, as you can see here. So what about intra-fraction motion? Because it’s very important to have an open face mask. Are we precise and are our, and are our patients stable during the one session of treatment or not? As you can see, we saw that it’s very good results because it’s less than one millimeter, even five oh 0.5 millimeters.

Dawid Bodusz (16:49):

So we saw that it could be a safe solution for this group of patients. So to briefly summarise the translation precision median residual translation was less than three millimeter for an open face mask, even less if we talk about longitudinal or lateral direction. And rotations were less than one degree, consistently outperforming closed face masks. So it looks better, what about the time which is needed to set up the patient in this project? Unfortunately, we didn’t collect any data about that one, but we had a presentation at this time. And it’s similar, and the results are similar to our experiences that we do not need more time to set up the patients if we have a well-trained staff. So, RTTs working on the machine, our results are similar to the other publications.

Dawid Bodusz (18:02):

It looks like these systems are safe and producible. So we can conclude that open face masks combined with SGRT clinically superior setup precision can safely replace conventional laser guides, closed mask positioning, Qfix and Klarity mask are functionally and can be interchangeable in clinical practice. Bite block selectively enhance rotational control. So pitch or rotation and routine use should be reserved for critical cases requiring sub-degree rotational margins and open phase surface guided radiation therapy workflows, reducing the need for skin tattoos and minimize additional imaging exposure. And last, maybe in the slide, it’s especially for our Vision RT team. So what does it mean AlignRT? It means accuracy, less setup time, improved patient comfort and precision, no additional imaging dose, real-time safety, and trusted technology. Thank you very much.

Daniel Holt
Principal Operations Radiographer and Centre Manager, The Christie at Macclesfield Radiotherapy, UK

Roxanna Zaharia
Medical Physicist, The Oncology Institute “prof.dr Ion Chiricuta”, Cluj-Napoca, Romania

Dr. Daniela Martin
Radiation Oncologist, The Oncology Institute “prof.dr Ion Chiricuta”, Cluj-Napoca, Romania

Robert Nolan
Physicist, Beacon Hospital, Dublin, Ireland

Tanith Lott
Clinical Specialist Radiation Therapist, Beacon Hospital, Dublin, Ireland

Video Transcript

Tanith Lott (00:04):

Hi everyone. So we’re delighted to be here and we’re going to be presenting, as we said on the evaluation of the Auto ROI, Automated Region of Interest Generation tool in AlignRT. And we’ll be sharing with you our preliminary findings from a testing site. So this was very much a collaborative project between our project team at home in the Beacon and Vision RT. So, before I dive into the auto ROI tool itself and the evaluation of it, I might just provide a bit of background on the Align RT and how we use it at the Beacon Hospital. So in 2014, we introduced SGRT for our cranial SRS sites. This was then expanded in 2017 to include the vast majority of our sites, extremities, thorax, abdomen, and pelvis. Then, in 2018 2019, we began our tattooless journey in conjunction with breast DRBH. This was then expanded further in 2019, and by 2020, we had gone completely tattoo-less and used SGRT for all our treatment sites.

Tanith Lott (01:07):

Our most recent updates were in 2021 to AlignRT. So as you can see, we use AlignRT quite comp comprehensively across treatment sites. So this provides quite a good testing bed for this Auto ROI within our department. Just to note that we use a Varian Edge and, most recently TrueBeam with SGRT AlignRT on both machines. So if we get stuck in the OIS in SGRT, we all know how crucial they are for patient tracking setup and subsequent treatment delivery. They need to be an accurate surrogate for the target. They need to contain enough topographic landmarks. If they’re too large, there’s the low frame rate, and they’re insensitive to local changes, whereas if they’re too small, they’ll give you insufficient topography and potential camera obstruction. There have been extensive studies showing that the selection of the ROI can directly affect patient setup and, therefore OAR and target dose.

Tanith Lott (02:06):

Even small changes in the definition of the actual ROI can lead to a decrease in setup error. So why might, why might we then move to motivate to automate the ROI definition? So it’s time-saving. We all know that the creation of manual ROIs is resource-intensive. It will increase consistency between patients. Currently, the manual process is quite user-dependent and can depend on the varying level of experience between TE therapists within a department, and it’s also better utilises resources and can lead to more streamlined workflows within departments. So, what does this auto ROI module designed to do? So it can define the ROI for most sites, pelvis, breast, brain, chest, and abdomen. It’s based on deep feedback from multiple clinical sites and adaptive-based modelling on successful ROIs. So it’s not AI. So then, a little bit about our actual study design. So we structured this in two parts. It was done on the prototype system. So the first part took place between November 2024 and January 25 and it was for pelvic breast, and thorax sites. And then in two the 2025, June, July of this year, we extended that to look at our SRS patient cohort.

Tanith Lott (03:36):

So this is just a video of what it looks like in clinical practice. So this interface should be very similar. So if you select your protocol of where you’re going to be treating your anatomical site, that will then import your surface for you. You’ll be given an option in two seconds to generate an Auto ROI. And under that there will be a dropdown menu for the different variants available for that site. So again, if we scroll through them, this is for a left breast; you can see that it is the inverted T that some centers might use. That’s just a general breast chest band. There’s a chest wall excluding breasts, which you might need, need for more pendulum breast treatments, your contralateral strip, depending on your department protocols, which or OY you use. And lastly, for the superclub treatment extended superiorly up into the neck area. So once you’ve picked the most clinically appropriate for what you’re trying to achieve in your departmental protocol, you can then save that. And that is the process. So as you’ve seen, once you pick your protocol so your anatomical site, there’s a dropdown menu of the different auto ROIs that are available for that site. So I’m not going to go through them all. You’ve seen in the video the breast DIBH one. So there’s one for the abdomen, pelvis and brain. And you can just see the different variants of what is available to use within your departments.

Tanith Lott (05:07):

So here are just a few examples of how the auto IROI performs. So this is done from the clinical version of the program, and this is for breast. So this is what we would use in our department. So, it’s the breast with a contralateral strip. If I show you, sorry, if I show an example, then for the pelvis, you can see this is again what we would use in our departments, focusing on stable bony landmarks within the pelvis. And that’s generated by the Auto ROI. Then, if we move on to the thorax, again, this is very similar to what we would do, and it focuses on the rigid structures in the thorax, up into the sternum, the rib cage, excluding any abdominal topography to exclude respiratory motion. And then if we look lastly at our brain, this is our SRS treatment sites. So we scan them with an open face mask. So, you can see the Auto ROI does a good job at contouring around the mask and around the kind of the nasal area up to the cheek level. So I’m going to pass you over to my colleague Kiron, or Rob, sorry, Kiran, sitting in front of me, who is going to go through the evaluation process and all the data.

Robert Nolan (06:23):

So as Tanith mentioned there, I’m going to go into more detail on our prototype testing, which we did at the end of last year and just the start of this year. So just to note for this first part, we did this study using a prototype tool of auto ROI on our own patients. So this is just a big spreadsheet showing kind of all the data we recorded. So we had kind of a mixed methods approach to evaluating auto or wise. So we had just a simple qualitative metric where we used this evaluation table on a scale of one to five, from unusable all the way up to perfect. And then in terms of quantitative data we also asked our Ortiz during treatment to flick between their manually generated ROI and the auto-generated ROI, and just to record the deltas for each.

Robert Nolan (07:17):

So we could do a, a quick comparison of both just to get some sort of quantitative comparison for this. But for this kind of part of the prototype testing, we mainly just wanted to identify any gross differences between what we drew manually and what the Auto ROI is giving us. So in terms of the study co cohort for this part of the testing we had a mix between mostly breast and pelvis. And in terms of the distributions of the ratings from one to five as we’d expected for a prototype tool, we have mostly three out of five. So, on the scale that just means minor edits required. So we have very few at the two range, which would be significant editing required. And very few kinds of further up. Maybe there are a few fours there, usable as is, but none.

Robert Nolan (08:08):

Perfect. So what should one expect from a prototype tool? Some small edits need to be made for these or wise, but very promising and considering this is quite early on at the end of last year, this is pretty impressive for us. And in terms of the quantitative data, so this is a comparison between the deltas when we’re using our manual and then we just change our ROI to the unedited Auto ROI and to see if there’s much of a difference in the deltas. In terms of the translational deltas, there’s very small differences in the very Latin long and you can see you kind of a breakdown here between pelvis and breast. So quite similar there for Latin long and then some kind of bigger differences in terms of rotation and especially role and pitch. But we think when there’s any sort of difference between your manual roi and Auto ROI, the deltas that would be most sensitive to any differences would be these rotational deltas.

Robert Nolan (09:10):

So as ETH mentioned this, there was a second part to this prototype testing. And this is actually done not on our patients, but on some ROI’s generated on anonymized patients is patients sent to us by Vision RT. So we did a study of 87 cranial SRS patients. So as Thomas mentioned, our center is a long history of using SGRT for cranial SRS patients. So since 2014, this was quite an important part of Auto ROI that we would’ve liked to implement clinically. So we had a different scale here from one to four, and then we have these descriptor boxes, which we can use to describe how we would improve these ROIs if we were using them clinically. And we just have a simple front on and two side views of each ROI.

Robert Nolan (10:00):

So again, the distribution of the ratings here. So quite similar to what we saw in the other type prototype version for the standard sites. We have kind of very few ROI’s that we would deem as being a one or a two, so requiring significant editing or unusable with the vast majority following in that three out of four range with an average of 2.91 for the cohort of 87 patients. So we are pretty happy with the results there. So in terms of the descriptors, how would we improve the ROIs that we were given for this prototype version? So the vast majority of edits that would’ve been required would’ve been insufficient coverage or topography. So basically, increasing the extent of the ROI is an issue that was present in this prototype, which we, we haven’t seen in the clinical version for cranial sites is a number of holes kind of presenting across the OOI.

Robert Nolan (10:57):

Again, we haven’t seen that in the clinical version, so that’s something that’s been fixed in the prototype. And then the kind of third most mentioned for these ROIs was the edges requiring editing. So possibly some rough edges that need to be cleaned out, but very few indications of any of the other descriptors. So just to give an example of these sorts of minor edits that might have been required for these ROIs for the cranial sites. So you can see in the far left, there we have at the superior extent of the ROI, we have some of the masks included which we don’t do clinically. Also, just an example there of the small holes that we saw in the ROI in the prototype version. So again, a very quick fixed just something we’d rather not have there.

Robert Nolan (11:43):

And then our third example here, which is you, you might see a few times is slightly too much of the cheek concluded that we wouldn’t do it clinically again. So, some early observations. So, from our center’s experience testing ROI in the prototype version and some kind of preliminary work with the clinical version the prototype testing shows that the vast majority of ROI is only require minor edits. So we get very few cases where we have an auto OOI that we have to do significant editing to that would take similar time to essentially using a manual ROI. So very promising. And the performance of OT ROI is is good and it’s consistent across all sites, which is quite reassuring. So, depending on whether it’s pelvis, breast or cranial sites, we saw very similar performance.

Robert Nolan (12:35):

And then yes, in, in terms of the cranial. So, insufficient coverage and topography holes in the oi are the most common reasons for any sort of edits. But again, again, that’s the prototype version. So just moving on to our next steps. We’ll have to do more testing on the clinical version to see if this performs differently from our experience with the prototype version. So actually, in the next few weeks our center’s planning on upgrading to AlignRT version eight. So we’ll be doing more testing on the clinical version of auto ROI, and we hope to implement it clinically for all sites very soon. So just some, some acknowledgements. It wasn’t just me and Tanith Lott working on the project. We also had a radiation therapist, Smith and Claire Day, and physicist Luke Rock. And we also had a lot of help from Vision rt, especially Connie and Andy. New and yeah, thanks for listening. And do you have any questions? Thank you.

Lisa Telford
Treatment Delivery Team Leader, Rosemere Cancer Centre, UK

Jayne Fletcher
Treatment Delivery Team Leader, Royal Preston Hospital, UK

Video Transcripts

Lisa Telford (00:04):

Hi. Good afternoon, everyone. I’m Lisa Telford, and Jane and I are both treatment delivery team leads at Preston. So we’re just going to talk about a few key tips that we use when implementing AlignRT and talk about one special group that we’ve recently done the mediastinal lymphomas for. So, very quickly, a brief overview of our department. Rosemary Cancer Center is in Preston in the northwest of England. We treat approximately 230 patients a day. We have eight machines, all Elekta, two that are in Harmony…There we go. Two that are Harmony, five that are Versa and one that’s being replaced to EVO at the moment. Our two CT scanners both have SimRT and all our treatment machines have AlignRT. And we have two remote systems as well that we use in data entry. All our systems were funded by Rosemary Cancer Charity.

Lisa Telford (01:02):

We went live in January 23. Yeah, so just a little further background as well. This is our radiographic staff. A majority of our staff are rotational because we’re so fortunate. We’ve got so many systems. I need all of these people trained for it to clinically work. So before we went live, we had a project team that was responsible for the rollout of SGRT in our department. That comprised of physicists, engineers, a clinician, radiographers from treatment and pretreatment and our planning team. And as a project group, we decided that the first site we would go live with was breasts. And this was primarily because we’d had a lot of problems with rescans resetting up breast patients. Like a lot of people, COVID came and the five fraction breasts came in great, but beam delivery was really long. So, doing breath hold, we weren’t confident.

Lisa Telford (01:58):

So we dropped breath-holding for this group of patients during COVID and we really wanted to pick it up. We’ve used the same approach on whatever site we’ve gone. So we’ve taken a small cohort check that we were happy with our workflow, and then implemented it for that cohort. We broke the breath down into all the different subcategories and starting with the first one, in a hundred clinical days, we had all our breasts, SGRT, and we dropped tattoos for this group of patients. We very, very quickly followed on to radical Thorax. And by this point, we now had two and a half linacs that we use in SGRT project team. We were delighted with where we’re at, and we got some audit data back. So we had some really good time savings in the three fractions, three fields, breath, but we also audited re-scan rates, re-imaging rates, and the time of imaging as well.

Lisa Telford (02:53):

The photon breasts are much quicker to image when we’ve used SGRT. So we’re really pleased with that. But our t our key tip really would be staff engagement. As I said before, we had a lot of radio geographies to get trained. So it started before we even had the systems aligned. My colleague did some in-house sessions about SGRT, what we learned at sessions like this, what we’d gone and seen in other departments, and what we were hoping to achieve in your super users. We brought one of our band sixes, again, reinforcing that support on the clinical floor. And then staff training, it’s really important to have your work instructions up to date. So we have an overarching competency for use of AlignRT and that makes it really easy to roll to the next site. We also have a troubleshooting guide, which has tips. So, allowing the radiographers to have that autonomous practice during those first steps of troubleshooting.

Lisa Telford (03:56):

Aside from this, we wanted to sort of tap into how the radiographers were feeling. So after we’d been clinical for a while, we sent out some surveys to just get some response back from them. We asked a multitude of questions. What was really clear was that both in sim and on treatment, the radio geographies were really confident using the system and crucial, which was the killer question, really. They felt it was easier to use AlignRT than conventional methods. What was really nice as well is things that the radiographer identified as benefits to the patient. So, no tattoosless manual handling were the things that we were trying to sell at the start. It was really nice that they actually saw that in practice. This was just a little bit more feedback. So we also asked them when they filled in the survey, just to see how long people were unqualified. Was there any difference between radiographers that being qualified a year and radiographers that being qualified for 20 years? We found no difference among the staff, but there were the same themes coming through, how quickly it was to get used to the system, how it feels like the system’s always been there.

Lisa Telford (04:59):

So we’d also ask the staff what site to visit next, and there had been mixed responses back. Pelvises, palliatives, we decided as a project team we were going to go with palliative as our next site for a couple of reasons. A, you get a lot of anatomical experience in there. We can flood our training because all the linac do some pelvic work. But most importantly, this is a group of patients who are in pain. So a quicker setup is a real benefit to them. A couple of interesting cases happen while we’re having this discussion. This lady here was a bilateral fungating breast treated with tangent pairs. Not strictly radical but not really a palliative setup. We used her with SGRT like we would with any tangent pair. And she set up really quickly in the last fraction, she was in that much pain. We were confident with the setup. We’ve been confident with the imaging. We admitted imaging for the last fraction.

Lisa Telford (05:52):

And I was called by the scanner team about this patient here. So she had one leg amputated again from gating lesion in pain. Where do you want tattoos? I don’t let’s SGRT. There were concerns about where the ROI would be in terms of stability, but really for this patient, I wanted the postural videoing. That was what’s going to help me on set. And you could imagine, you know, trying to read the comments that pretreatment has written about how to set her up. This was so much quicker. So I treated this lady and the radiographer who treated her instinctively knew when she got on the bed how to set her up. That’s how easy it is taken from one site with SGRT, to the next site. They just instinctively knew how to use the system to position this patient. We set her up, imaged her and treated her quicker than I got her on and off the bed.

Lisa Telford (06:42):

So it was a perfect case. Each time we’ve gone live as a project group, we’ve stopped reflected what we learned. These are some snapshots that we learned from the palliative patients. So when we had our training, we’d seen the FSD function, and we’d nod along and said, oh yeah, but we never really used it for the breasts or the thorax patients. But it really streamlines your workflow for palliative patients. The use of gated captures. Now we use it as standard for the thorax as you don’t need to, but for work construction purposes, it was easy to pull it in for the thorax. So when we were having the radiographers was seeing that there was some ROI instability over the breathing, they instinctively knew I’ll do a dated capture to capture that will resolve that issue. And the Postural Video is such a game-changer. It makes things so much easier to set up radiographers. We naturally want everyone straight. Then we take an image and realize they weren’t that straight, and scanner, postural videoing takes that away because you’re just reproducing that position.

Lisa Telford (07:44):

So where have we come? So in a couple of years we’ve done really well. We’re not quite up to Mike’s level, not fully there, but nearly we’ve got all our pelvic workload on. We don’t tattoo for breast thorax pelvis patients, palliative patients, whether we’re using bolus, not using bolus, we’ve got some of our SABR workload on. So we’re about 75% of our patients are treated using SGRT as the primary setup tool. Still a few things that we want to achieve. So we are currently trialling our open-face masks for SRS patients. We are actively looking to see what masks we’d like for head and neck patients. Very, very keen to get the SGRT on for the Sabre livers. That’s Jane’s goal. And the SABR spines and really going to what our goal was when we got this was to be fully SGRT.

Lisa Telford (08:37):

So just another key point about that staff engagement. You really need your team leaders to be involved because their confidence would radiate down to the staff, and a few little tips would really to get them engaged in here. So when I was over breast machines, I had eight work instructions for breast, whether they were breath hold and all the different subsections. There’s one. So when you have a new member of staff getting their competencies signed, it’s so much easier to move staff around the department. Like I said, taking one area from SGRT to the other area, once you know how the system works, it’s just so easy. So moving staff around from machines is easier, and stuff that have manual handling issues that perhaps can’t work on breast machines, you move patients so much less. So that’s much easier on the rotor. And just some last sort of tips.

Lisa Telford (09:26):

You need that initial project group for multidisciplinary work, but define your goal and that will vary. I appreciate that, depending on how many systems you have in your department, start that engagement with staff right from the start. Get the excitement going. Whatever site you choose to go with, take a small cohort, check that your workflow is correct, but don’t procrastinate. Move and go with that. Make sure your documentations update and keep updating any troubleshooting guides that you’ve got. Make sure you’ve got your super users to hand so you’ve got the confidence on the treatment floor audit to celebrate the work that you are doing. And that audit work can start now, before you’ve even got your systems, you can get your treatment time data. Great way to engage the staff. Everyone’s after a bit of CPD think about using SGRT for those challenging cases.

Lisa Telford (10:17):

So you may have two systems and think, right, I’m going to use it for breasts, but every patient can benefit from SGRT. So engage with pretreatment, engage with clinicians when they know there’s a patient who might be a difficult setup. We want to get away from health inequalities and this is a perfect system to allow to do it. It will also grow your confidence and help push your argument to move the workflow of SGRT forward. Celebrate all those successes internally, externally with alcohol, without alcohol, however you want to do it. And when you train more people or move to the next site, revisit those standards. Are people checking the Postural Video, are the ROIs as you said? Make sure that you’re just checking those standards throughout. So I’m going to hand over to Jane, and she’s going to talk about how we’ve been able to do this with the missing lymphomas.

Jayne Fletcher (11:14):

So yes, like Lisa said, my name is Jane and as a team leader we’ve been looking at implementing mediastinal lymphoma since roundabout 2023 when a clinician first mentioned it. So our current practice is probably similar to most centers without SGRT patients are in a closed face mask. Not really very conducive to you actually doing SGRT and breath hold. And what we decided we would do was, after the clinician first mentioned it, we started having some initial conversations. We thought let’s get on board with mediastinal lymphoma in DIBH And because we’ve got experience using the elect active breathing coordinator, that was our initial plan. Obviously, this was all pre-COVID, pre SGRT installation. And so we then had a brief pause, moved on to implementing SABR Liver and came back to it back in 2025 when our clinician turned around and said, I’ve got a patient for you, get ready. So a bit of a background into DIBH in the department. We started off pre-COVID with the non-assisted DIBH. Primarily on our two fielded left side. We got the electro ABC system started, using that for our SABR livers, and rolled it out to a few difficult cases in terms of lungs. We then got the AlignRT systems along with the RTC, and so we introduced that for our left-sided only. We have since rolled it out and are now doing the occasional right side but are hoping to continue that rollout so that we get all of our right sides in DIBH as well shortly.

Jayne Fletcher (13:07):

So like I say, our initial plan was will we use the ABC? Seems the best thing to do. It’s a gating system so we thought let’s, let’s have a look.

Jayne Fletcher (13:20):

It is time-consuming. It takes us about an hour to scan somebody and then an hour to treat them per session. And that’s because of the amount of coaching that the patients need in order to be able to regulate their breathing. And so we just looked at it, thought hmm, potentially 15 fractions within our with ABC that takes an hour is a lot of time on a linac to lose. We then had, by this point, a lot of experience doing DIBH using the RTC system. And so the easiest answer and the most obvious answer is let’s do it using AlignRT.

Jayne Fletcher (14:05):

So it has enabled us to reintroduce a breath-hold since COVID. We’ve also expanded, as I say to all of our left-sided patients with DIBH, and we are also now doing the occasional right side, as I’ve said, with the aim of us getting all of our right-sided patients on DIBH shortly. The RTC is very easy for patients to use. But you do come across the occasional patient who really struggles to understand what the screen is trying to show them. So actually, it’s not the easiest tool for everybody, but it works for about 90% of people, and even those patients that can’t tolerate having the screen above them and can’t understand it, still manage a breath hold using AlignRT. So we did have panic stations. The clinician, as I say, came to us with the patient and said, I’ve got one, let’s get ready, let’s get on with this patient. So, due to the fact that they have a family history of cardiac disease, it was quite important that we got this patient on DIBH, and if we weren’t able to treat them, they would’ve had to have gone to a different center which would’ve involved an extra hour’s drive for them.

Jayne Fletcher (15:24):

So we then had to look and see what was missing in our systems, what we needed to do to be able to get ready. And that involved having a consideration of immobilization what you do. Like we are at the moment use, we’re using closed face masks for any head and neck immobilization. So that wasn’t going to work for us. We’ve got our breath hold instructions from our DIBH patients and also from doing the liver ABC. So we were able to adapt that for the lymphoma like Lisa’s already mentioned, come up with your work instructions. We’ve already got competencies that we were able to adapt. We’ve got a troubleshooting guides that we were able to adapt and we got all of our quality system documentation done very quickly.

Jayne Fletcher (16:13):

One of the key things we looked at was trying to preemptively troubleshoot AlignRT. We know that we get occlusions at certain angles. We know that that was going to be a problem with a lymphoma patient who was in breath-hold. So what we did was get one of our very willing or not so willing colleagues to lie down on the bed and have a look and see what we could do. So having a look at where we would anticipate a mediastinal lymphoma isocenter to be, we decided along with our planning colleagues that we would try and situate the isocenter a little bit more anterior within the patient and also offset it superiorly so that the patient was further out from underneath the gantry head so that the cameras had more of the patient that they could visualize. I’m not going to say that trying to do that before a patient arrived has solved all of our problems, but it went a long way and helped us. We then had to think about like we’ve said occlusions defining an ROI, we had a good idea, we’ve got a lot of experience but it doesn’t always work out how you expect it to.

Jayne Fletcher (17:23):

So we had the first patient came in, we did the CT scan on him, we did a bit of coaching with him. You have to assess that they can manage the breath hold, hold it, understand instructions. And unfortunately because of the chemotherapy, this patient did have quite significant neuropathy. And so what we found was that although he managed to hold a pole for the CT scan during treatment, his hands were actually becoming very numb. So what we were able to do using the SGRT system was to drop his hands down slightly more behind the back of his head. And with the SRT system and postural video you could see that that wasn’t making any changes to his positioning. So we were happy to continue without needing to do any re-scan or re-plan. So just a quick look at the difference in his lung volumes to show the benefit that you do get from trying to treat patients like this. In breath hold, as you can see on the right hand slide with the lung volumes on it, it is considerably less volume than the breath hold scan. So we put an ROI on using our experience of thorax and breast, what we thought would look good, what we thought was going to work for us. And unfortunately, that wasn’t really the case when it actually came to the treatment session.

Jayne Fletcher (18:44):

So over the course of the first couple of treatments, we did amend the ROI considerably. Now this is due to the fact that when we tried to do a gated cap, sorry a capture post cone beam, the systems were coming up with quite an awful lot of black patches, which you can’t see on these slides here. But what we were able to do was use those black spots that it couldn’t see to then amend the ROI and cover everything that it could actually capture. We broke quite a few of AlignRT’s rules with this ROI and the fact that it isn’t over the ISIS center and it isn’t off the diaphragm. So with the Elekta system we used a fast acquisition. So it’s about a minute, about a minute of breath-holding for the acquisition to go around the patient managed it in two breath holds. If we had done this with the ABC system, it would’ve been three and a half breath holds to acquire a scan. So from the patient’s point of view it’s a lot less tiring for them to be able to manage.

Jayne Fletcher (19:58):

So just to show the image quality that you do get in being able to see these volumes when you have acquired your cone beam, obviously breath hold is going to always give you a better quality image but we were actually astounded as to the quality that we, that we managed to achieve. Especially as this is a fast acquisition. So as you can see, most of the anatomy that you would want to be looking at is very, very clear. Our clinician was also very impressed with the quality of these images. So we did then get a second case a couple of months later. Slightly younger gentleman, we tried due to the neuropathy in the first patients case we tried to put them in a body fix vac bag with their arm still up but a little bit more relaxed to hopefully help them feel a little bit more comfortable. Sadly that inter does interface slightly more with the ROI for the patient. So you do need to think about that when you are looking at your immobilization choices. Sadly, this patient had two fractions using the SRT system and due to his inability to be able to manage DIBH and achieve his breath-hold position it was a joint decision between the patient and the clinician that they would be re-scanned and re-planned free breathing in a mask as per our previous practice.

Jayne Fletcher (21:28):

So in terms of moving forward for us it is knowing that these patients are probably a wing board, nothing that’s going to be occluding space for an ROI, so not coming up and wrapping round the chest like a body fix probably would do our second case, our SimRT systems, because they were quite rotund in the stomach, if the SimRT had nothing that it could pick up on the patient. So you have to think about having a practice when you’re scanning them. That’s a little bit more old school that you can utilize. So we did manage to scan him. We used a manual breath hold and we got the two scans which is how we’d implemented our breast breath holds before we got SimRT. So we had experience with that as well. Think about your ROI adaptation with a lot of experience on SGRT. You can on the spot and on the fly, adapt your ROIs very quickly, and that’s where having super users but staff that feel very confident with the system, who have got lots of experience and have used it for multiple sites, they all feel more confident in being able to adjust an ROI using our previous DIBH experience.

Jayne Fletcher (22:39):

We’ve got the competencies for breast DIBH and we’ve got competencies for thorax. So we were able to sign a lot of our staff off very quickly with this system. If we had used the ABC, we would currently only have 20 staff signed off to use ABC due to its infrequent use. So it would’ve been a lot more of a training burden to get more staff trained. And then, like Lisa sort of mentioned, it’s then thinking about how you use this, even this experience with DIBH for the lymphomas in how we roll out to even more sites. So our, our current plan is looking at the livers and hopefully getting our spines, SABR spines on SGRT as well. So yeah, from Lisa and me, thank you very much, and we would just like to thank all of the staff at Rosemary Cancer Center for their ongoing support and really their speedy adaptation. And as radiographers, we don’t always accept change very quickly, but our guys have really taken it on board and have flown with it. So thank you very much.

Orla McKivitt
SABR/SRS Clinical Specialist Radiation Therapist, Cork University Hospital, Ireland

Video Transcript

Orla McKivitt (00:04):

So my name is Orla and I’m the SABR and SRS Clinical Specialist Radiation Therapist from Cork University Hospital. And I’m going to talk about our liver SRS program and how we’ve managed to implement an SGRT workflow for these patients. So I’m going to quickly go through our vision, our journey with Vision RT and how we implemented a liver SABR free breathing and an end expiration breath-hold pathway for these patients. I’ll then go through the motion management and the challenges that we have faced. So just quickly, a bit of background, I won’t go too much into this, but we went live with a line RT back in 2019. We went tattoo-free, we used it for our DIBH breasts. We went live with liver, lung SABR, then liver SABR, and then we moved on to SRS. And recently, we went live with prostate SABR.

Orla McKivitt (00:50):

In the new year, we will be doing bone nodes and adrenals as well. So when we began to discuss implementing liver SABRE in our centre, we began our meetings in 2023. And this is the team here in the photograph. So includes our radiation oncologists, our RT’s, physicists and dosimetrist. And our main concern when we began meeting was how were we were going to do our motion management. So from the literature, we know that these abdominal SRE patients should be having end expiration breath-hold, where possible, as that’s the most reproducible phase of breath-hold. So we were considering how we would implement this. We have been using Vision RT for so long. I really felt strongly that we could use this within our motion management, but there were concerns from the wider MDT, especially as we had new radiation oncologists join our department who had no experience, we were using it, and that kind of trust maybe wasn’t there yet with the system.

Orla McKivitt (01:49):

So the two systems you might be familiar with are ABC and RPM. And I’m sorry if you are a fan of ABC I am not. We had used ABC in our old center for our breast DIBH patients. And look, it works. But we found that there was a lot of patients who couldn’t tolerate the ABC system. And when we considered the abdominal SR cohort of patients, these people are in a lot of pain. They’re uncomfortable, they’ve often been refused surgery, they have had multiple taste procedures and microwave ablation. So, if we had healthy breast patients not being able to tolerate ABC, how were our abdominal SABR patients going to feel using ABC? Also with the ABC we would have to buy new systems. We all know money is tight.

Orla McKivitt (02:40):

We really wanted to get liver SABR up and running, as it was not a treatment option for patients in Ireland in a public center at the time. We were also concerned about the extra staff training, but there is a lot of publications supporting its use out there and its ability to reproduce the breath-hold amplitude. Same with RPM. We’re an elected department. But again, we didn’t look at RPM too much because of that. But there is data out there supporting the use of RPM and its ability to reproduce breath-hold amplitude. So my question was why not use AlignRT? There’s no published data. And kind of echoing what Mike said earlier, though, sometimes you just have to take a jump. We were confident in it. We knew that it worked for our breast DIBH, but we had done some lymphoma thorax patients in DIBH. So we knew that this could work. There were a lot of technical aspects we would need to consider. There would be some staff training, but then, how accurate is it going to be with these patients? We want to implement a margin of five millimeters where possible and we going to reproduce the breath-hold accurately.

Orla McKivitt (03:52):

But as I say, we were successful in using it. The training we would need for RT’s were limited and Vision RT put us in contact with the Alfred in Melbourne Australia, who had been using it for quite some time and they were really confident in using it. And they said, look guys, this works. We may not have published our data, but it does work. And they gave us a lot of tips and support when we looked into to implementing this. So the key considerations that we had to make when we were meeting to implement this were: What would our monitoring tolerances might be, what would be realistic for an end expiration breath-hold patient is one millimeter is a two millimeters. What, what’s going to be realistic on set but also what’s going to give us that accuracy, what our I is going to look like?

Orla McKivitt (04:39):

So we’ve discussed ROIs a lot here today, and I’m going to go through later what we decided on our ROIs. So the camera occlusion. So, the camera block, what’s going to look like? So you’re used to doing a DIBH patient on a breast board, which is at an angle, so you’re not getting that shadow that you would get when the patient is flat. So we were concerned as to how our treatment captures would look. Onset CT simulations, we have the CRT package as well. So how was our capture going to look in ct? Where were we going to put our tracking patch? And also, how are we going to implement a multi-phase IV contrast CT protocol in end expiration breath-hold using vision rt? It’s complicated. So that was something that we really had to do a lot of work on. Then what kind of BCTs were we going to acquire, what our capture quality was going to be?

Orla McKivitt (05:31):

And also, how are we going to implement our moves? So we know with Vision RT, when we’re implementing our moves after we’ve done our image registration, we lose that tracking of the patient’s surface. And when you’re using the hex pod system with Elekta, when you’re correcting in six degrees of freedom, it can take a considerable amount of time if you’ve got rotations near three degrees and sometimes you have to apply a vector move. So there are two different sets of motion. So we were concerned about how we would verify that the patient has maintained the breath during implementation of the moves? So this is the very simple pathway that we came up with for our patients. So just to say that we do have an index probation breath-hold pathway, but we also have a free breathing pathway. And I’ll briefly touch on our free breathing pathway as well.

Orla McKivitt (06:19):

So first of all, our motion assessment. So this is the biggest change in our pathway, right? So we’ve never done a motion assessment appointment before. And I know we’ve touched on it earlier. Some questions about how you know your patient is for DIBH? So first of all, we bring them in. This is done in the linac. So this is about a 45-minute appointment inside in the linac. We make the vac bag there and then, and then we use a generic motion assessment patient file on the SGRT terminal in the room. We take a capture of the patient in free breathing and then we coach the patient into end-expiration breath-hold. So they have to be able to hold a consistent end expiration breath-hold for 15 seconds. That is our minimum allowed time. And then once they’re coached into it and they can, we’re happy that they are maintaining it for that minimum of 15 seconds.

Orla McKivitt (07:08):

We take five KV cine fluoroscopy style images while the patient maintains end-expiration breath-hold while indicated by the SGRT system. On those fluoroscopy images, we are assessing the intra breath-hold motion and also the in breath-hold motion. So during those 15 seconds, you’re having a look to see is your diaphragm position is holding for that whole 15 seconds, but also you’re looking between each of the five breath holes is the diaphragm is reproducible to the same level. So each breath-hold, are they going to the same amplitude? So we have different tolerances for that. So the ideal is not to two millimeters but if they are three to five millimeters, we will still continue an end expiration breath-hold, but we will consider greater margins if they fail that they’ll move on to the free breathing pathway. The CT simulation workflow that we then came up with.

Orla McKivitt (08:05):

So the patient is set up as per the motion assessment. This is done the following day. We don’t do this on the same day due to patient fatigue. We use the SimRT module to take a surface capture and we place the tracking patch on the sternum. The most important thing with putting your tracking patch and placing it is that you know your patient, how they breathing? And you have to sit and watch your patient and let them relax. A patient quite often will start breathing through their chest and then change to breathing through their abdomen if they get quite anxious as they’re lying on the bed or vice versa. So understanding your patient and understanding their breathing pattern is paramount. We do a free-breathing CT first for the free-breathing surface. So that is done after contrast injection.

Orla McKivitt (08:54):

So this is the arterial phase M IV contrast that we’re doing for the free breathing scan. This is where it gets tricky. So you now want to catch the patient in the venous phase of the IV contrast, but you also need to move your couch to the start position. You need to take a new surface capture, and you need to place your tracking patch where it needs to be. You need to coach the patient into end expiration breath, hold to the correct amplitude, and you have about 25 seconds. So this, this is challenging, but the breath-hold takes precedent over everything. So sometimes you may sacrifice your scan delays in order to make sure that your end expiration breath-hold is accurate and correct. We do tend to have diagnostic CTs and sometimes MRI that we will fuse if there is problem with target delineation.

Orla McKivitt (09:42):

If the contrast scan isn’t the best quality. We do a delayed phase scan as well for our primary liver cancer patients. So that’s done four to six minutes after contrast injection. It’s then planned. I’m not going to go into that. This goes into the magical world of dosimetry and comes back out. And then we’re ready to go. So this is just an example of what you will see in your SimRT module. So just an inverted DIBH trace there. So you coach the patient to take a deep breath in, breathe out and hold. And this is an example of the surface capture that we would get in. The MRT generally, you can see that we’re missing some of the surface on the top, and that’s generally just because they’re lying flat rather than on a breast board.

Orla McKivitt (10:30):

When you have a male patient, you get less than that, but you can see here it’s perfectly fine. You can see the patches where it needs to be, and there’s enough information there. So just to touch on the free breathing pathway, so again, a similar T surface capture is taken. We put the tracking patch on the sternum, and we make sure the patient is coached into a regular breath. Where possible we’ll actually coach the patient into a shallow, regular breath. And this allows us to set tighter tolerances on the SGRT tracking. And that just makes sure that we’re minimizing that motion, and we are doing an ITV method on this planning. But it does just keep that motion down. Some patients are not eligible for coaching into a shallow regular breath and it’s safer just to let them do their own thing.

Orla McKivitt (11:17):

We do a 4DCT scan, and we do our multi-phase contrast on our 3D scan. So no offence to the physicist in the room, but on the left here, we see that this is our trace that you get from your QA. So our physics sometimes live in an Instagram world where everything is perfect and beautiful but on the left is reality. So the RT’s, so this is a real trace from a real patient, but just to highlight that, although it doesn’t look pretty, this is a perfectly usable trace, and this produces a lovely four d ct. So just to, to highlight that, sometimes it might not look, look exactly how you expect it to look, but this is, this is perfectly fine. So once everything is planned, we do a day zero for all our end-of-expiration breath-hold patients.

Orla McKivitt (12:03):

So on day zero, it’s a dummy run of the treatment. And the reason that we kept this appointment, although, you know, we capacity tighten departments and, and you’re looking for time anywhere, everywhere you can, what’s so important about keeping the day zero and the end expiration breath-hold patients is that you need to test your ROIs. So the patients generally have different ROIs depending on their body shape and depending on their breathing type. So it’s really important that you can spend that time in testing the ROI with the pre without the pressure of delivering treatment on that day. We also check where our camera block is going to be so that we can predict during our cone beam CT where we’re going to have that block and where we’re going to lose that tracking of the patient so that we can, if it does drop out, we know that it is camera block and we know to expect it, we check clearance.

Orla McKivitt (12:54):

Generally not a problem with our liver patients and it’s a good opportunity for the patients to practice end expiration breath-hold again because it’s been about two weeks since they’ve had their CT simulation and you find that sometimes they kind of have forgotten or they’ve, or they’ve got a bit too anxious about it. So it just gives them that, that opportunity. We do acquire a CBCT during the end expiration breath, hold on day zero. And that’s just to make sure that there haven’t been any significant internal changes between CT, so the customizing of our ROIs. So here are just a few examples of the different ROIs that we have. So we do go with arms up for our patients standardly but we are very quick to put arms down. As I say, the ability for the patient to reproduce their end-expiration breath-hold is paramount.

Orla McKivitt (13:43):

So we’re quite quick to put arms down when needed, and sorry to the Dosimetrists the room, I know it’s a bit harder to plan. You can see here that we’ve got one ROI that’s actually quite large and that would generally be if the patient is breathing through their belly a bit more. So you’d include a bit more of the abdomen. Some of them are just a normal thorax, ROI, but what you probably notice is that it does come down over the rib in all patients to catch that motion. Just under the ribs of where the, when the diaphragm is moving. One thing that we have found is that we sometimes have to take a little circle out of the center. If you’ve got quite a slim patient, the heartbeat and the motion there can actually be quite significant. So sometimes you have to take the ROI out there just to, to stop that from being counted into your motion.

Orla McKivitt (14:30):

So for treatment, they’re set up as per your CT simulation and we do a 3D CBCT in end expiration breath-hold. We do an image registration and six degrees of freedom, and we coach the patient’s intent and expiration breath-hold and apply all the moves in six degrees. So I mentioned earlier the challenges with applying the moves in six degrees, especially with the hex pod system. So what we found is if you have a large move to make, if your rotations are close to three degrees on any of your rotations, you’ll have to apply a vector move. So your bed will move, and you’re a lot longer and your vert first, and then you’ll do your hex pod move. So what we decided to do was to do the moves in two stages. So we first the patient into end expiration, do the first shift in the lot long in the vert, take a surface capture and give the patient a break.

Orla McKivitt (15:16):

Once the patient is ready, we then coach them back into that surface, apply the HEXA pod move and then take another surface capture. And that works quite well. Some patients are well able to hold the breath but you kind of get to know your patient and you know if they will or not. We then delivered the treatment and our first, probably more than our five patients, actually, we did post-treatment BCTs, which validated the pathway. So just to briefly touch on our free breathing pathway. So if you can see here the orange and the blue color on the CBCT here. So the orange is the liver max and the blue is the liver min. So these are contoured on our four DCT. So you have a maximum and minimum position of your liver based on your maximum inhale and exhalation.

Orla McKivitt (16:01):

So they’re contoured and exported to the CBCT system. We then take a 3D, CBCT and we apply all moves in six degrees. Our tolerance is on SGRT two millimeters and two degrees for our free-breathing patients. So once the moves are applied, we take a confirmation 4D CBCT and we deliver the treatment. But if this plays, so this is our 4D CBCT with our two millimeter tolerances. So you can see here that the diaphragm is staying quite nicely within the two lines. So you’re just ensuring that your patient breath is staying within what you’ve expected from your 4D CBCT, from your planning.

Orla McKivitt (16:41):

So one of the most important tools and one of the most important developments in the AlignRT is the deformation tool. So this allows us to really understand where the patient is breathing and you can see where the motion is actually happening. So, where this is really important is the motion assessment. So you can, we have now changed our protocol to use the deformation tool to actually identify where the patient is moving. So instead of doing it by eye, you can use the deformation tool to help you see where that’s coming from. And also then, when you’re on set, it gives you a really nice indication to if the patient’s breath is incorrect or if they have moved somewhere else, and it’s actually not their breath, that’s the problem. So if I play this here, you’ll see the patient is getting coached into taking a deep breath in and they slowly start breathing out.

Orla McKivitt (17:35):

There you go. Down comes, the bark goes green, everything goes green and you beam on. And it’s just really lovely to demonstrate here how well the system can work for end expiration breath-hold without having an invasive option for making sure they achieve that breath-hold. But it’s not been easy, it’s not that easy. It sounds easy, it’s not. We’ve had a lot of challenges and we’ve had to learn as we went. We didn’t have the benefit really of having many centres to reach out to for support. So we had to learn as we went along. So the breathing types that we, I touched on earlier, you can have a patient that starts off breathing through their chest and halfway through treatment, they decide to start breathing through their belly, be they become uncomfortable or, you know, become even more relaxed and start breathing through their chest.

Orla McKivitt (18:26):

So understanding where the motion is happening and where the breath is coming from is really important. The ROIs, we were really strict with our ROIs at the start. We thought, okay, we’re going to have a free breathing ROI, and then we’re going to have a breath-hold ROI and then we’re going to do this, this, and this, and you’re not to touch it. And that was all great until it wasn’t. So our RT’s now are really experienced in editing your ROIs to maximize your breath-hold reproducibility. Our camera block. So again, we’ve just got really used to where this generally occurs and knowing when it’s camera block and knowing when it’s the patient that’s moving. And somebody touched on earlier the different tools available in SDRT that when you can see the patient, you can see that they haven’t breathed out on your, on your cameras.

Orla McKivitt (19:16):

And then finally, the coaching training for the RT’s. And it sounds like something small, but if you have somebody coaching you through your end expiration breath-hold and suddenly there’s a different voice on the mic the next day and they’re telling you to breathe com, you know, with using different languages and different words, it can really impact the patient. Some patients really benefit from breathe in, breathe out and hold, but some patients need and hold and hold and hold and hold. You have 10 more seconds. You can do it, you can do it, you can do it. Some patients benefit from that. And being able to learn who will benefit from that and who won’t is a real skill that the RT’s need to develop. And it is very different to DIBH coaching somebody into end expiration breath-hold. It really is not the same. We also liaised with our respiratory team in the hospital and on how best to achieve end expiration breath-hold. So it’s really important to include your physios and your respiratory team and how best to get the patient to reproduce the breath-hold.

Orla McKivitt (20:17):

So we’ve successfully implemented this, it says here in 19 liver SRE patients, but we’re up to 22 since I wrote this slide. The vast majority of our liver patients SABR patients, are in end expiration breath-hold. We have had three free breathing patients who are unable to do end expiration, but it just shows with the correct coaching and time and patients that you really can get these patients into end expiration. breath-hold. We are currently running a reproducibility study for end expiration breath-hold so that we can directly compare it to

Orla McKivitt (20:46):

ABC and RPM. So we’re aiming to publish this next year, but our preliminary results show that the int factional difference in breath-hold amplitude is less than two millimeters between CBCT, which is actually slightly better than the data on ABC and RPM. So thanks so much for listening and thanks so much to all the SABR team at Cork that went with me on this. It was a hard sell at the beginning but with us working together on good collaboration, we managed to implement this pathway. Thank you.

Joana Gomes
Chief RTT, Kantonsspital Winterthur, Switzerland

Video Transcript

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.

Aaron Singleton
Macmillan Treatment Team Leader, Imperial College Healthcare NHS Trust, UK
Patrick Hans Dudley
Macmillan Therapeutic Radiographer, Imperial College Healthcare NHS Trust, UKOlivia Channon
Principal Physicist, Imperial College Healthcare NHS Trust, UK