Xinran Zhong, PhD, DABR
University of Texas Southwestern

Video Transcript

Xinran Zhong (00:04):

So my name is Xinran, and I’m currently a physicist working at the UT Southwestern Medical Center. And today I’m excited to share our experience using the AlignRT InBore system to guide the breath hold and its application on a CBCT guided adaptive system. I have no conflict of interest to disclose.

Xinran Zhong (00:34):

And here is the outline of today’s presentation. So, in the beginning, I’d like to briefly talk about the CBCT guided online adaptive treatment for whoever is less familiar with it. And then we’ll move on to the breath-hold application in the online adaptive radiation therapy and its benefits. And then I will briefly introduce how we use the all AlignRT InBore system in our clinic Ethos, and I will go into the detail of the implementation of the breath hold from the simulation to treatment and share some preliminary results using on the inter-fraction motion analysis and time cost. And in the end, I’ll summarize some key takeaways. By the way, I think it’s still automatic move advanced slides.

Xinran Zhong (01:31):

So the CBCT guided online adaptive system is to use the daily CBCT and for the counter planning and dose calculation rather than the simulation CT. So in this way it can effectively address the infection motion and with the physician counter the daily target and OAR counter and with a potential with a reduced margin, we could achieve better target coverage and the lower OAR dose. And on the right, I show we’re using the variant Ethos system in our clinic. We have two Ethos systems equipped with a hyper set imaging technology. And as we can see from the picture, the Ethos have a ring based gantry. And the hyper set image technology enable us to acquire the city image with six seconds image acquisition time and with an improved image quality.

Xinran Zhong (02:36):

And with the adaptive therapy, help address the intersection motion. How about the intra-fraction motion? We know that the breath hold is an effective way to minimize the intra-fraction motion and in the adaptive word if we can minimize the motion within the image acquisition, it has another benefit of to reduce the motion artefact, which could improve our image quality. This is especially useful for the patient with a lot of gas in the abdominal area. And with the improved image quality the physician could have more confidence on countering the target and OAR, and it can also potentially help with the AI-based auto-countering that could help accelerate the workflow. So on the right we could see an example. The top row shows the free breathing CBCT and the bottom row shows the DIBH hyper site imaging and we could see the improvement in the image quality. And of course, the breath hold has other conventional benefits of potentially increasing the distance between the target and OAR, and also the potential for further margin reduction.

Xinran Zhong (03:58):

And to achieve a more consistent breath hold we know that surface guidance is a good option to guide the breath hold. And in our clinic, we equip the AlignRT import system on both of our Ethos systems. So here is just a very general introduction. So the AlignRT board is designed to be compatible with the Ethos system. So there would be one set of camera that’s a ceiling-mounted camera that’s used to track the surface at the set up ISO outside of the bore. And when we send the patient inside the bore, there will be a ring-based camera that’s used to check the surface in the middle of the treatment. And here we summarize some key numbers that we got from the technical specifications. So as we can see between the setup cameras and the InBore cameras, the accuracy as well as the FOV are pretty comparable.

Xinran Zhong (05:01):

So with the AlignRT InBore system installed, we not only use it for the breath hole guidance we also use it for the free breathing setup. So the application includes to achieve a more consistent setup across the machines in our situation is between the health and Ethos for our adapt on demand treatments, and it would also help with the setup for breast patients for the same omitted treatments and can be used to remake the immobilization device as well if we have any setup modification or if I have a deflated backpack and so on. And on the right, I included a pie chart showing the case distribution in our clinic from 2021 to 2024, like the site distribution. As we can see, we have a relatively even distribution across different sites. And try to design and test out our breast hole workflow, we pick the breast and abdominal lymphoma case as a starting point.

Xinran Zhong (06:15):

So, before the implementation, we do have some questions in mind when we design the clinical workflow. First, what’s the residual infection motion of the target when we do the SGRT-guided breath hold? Second, what’s the cause of time to introduce the surface guided breath hold to the adaptive workflow? And third, how does a longer treatment workflow affect the consistency across different breath holds? So after some discussion, we implemented the following workflow. So a successful motion management usually starts from the simulation and planning. So in our situation with a difference for the breast and the abdominal cases, we have a slightly different reason why we want to use the breath hold and also the target to surface distance are also different. So we try to design the simulation evaluation slightly differently based on the application.

Xinran Zhong (07:20):

So for all of our breath-hold patients our therapist would have a very thorough breath-hold coaching and evaluation using the SimRT. And so to ensure that the patient can have a long enough and consistent breath hold before we proceed with the CT. And when we are done we will acquire some CT images, and usually a physicist will be there to evaluate the CT image quality before we release the patient from the clinic. So for our breast patients, we usually would acquire one free breathing and one breath hold scans. And here the evaluation would mainly focus on the separation between the free breathing and breath-hold surface. This is to ensure that there is a symmetric value to use the breath hold for the breast planning. And we would also evaluate the shift of the spine between the free-breathing and breath-hold images. We found that this is a good indicator for a more consistent breath hold during treatment. And for abdominal cases, we would acquire more breath-hold scans. So we would usually acquire three breath-hold scans and we would compare the surface consistency as well as the target consistency. If we see significant motion in between different breast hole scans, we will definitely communicate this to our physician to make sure the final PTV margin could include this motion into consideration.

Xinran Zhong (09:05):

So after the simulation and planning, we will move to the treatment and we will use the RTC device to help the patient to achieve a more consistent breath hold. And here the setup procedure would be we set up the free breathing set up the patient with free breathing as a setup iso, and then we will move the patient into the treatment ISO and try to evaluate the breath hole consistency. And if we see a new consistent breath hole that’s different from the simulation, since it’s an adaptive machine, we’ll just recapture the surface before the Cone Beam CT. And in the whole treatment process and the imaging, we would use three millimetre motion for the vertical, lateral and longitudinal.

Xinran Zhong (09:56):

So here is a example accelerated workflow for our setup. So the therapist will use a Posture Video at the setup ISO and the free breathing surface to set up the patient, and then they will shift the patient into the treatment iso and they will also switch the surface to the breath hold surface and see if the patient’s breath hold can match the simulation. And this patient is a pretty great example. So after this verification, they will just step outside of the treatment room and then start the six seconds Cone Beam CT acquisition. So as you can see over here the patient only need to hold his breath for six seconds before the Cone Beam CT is done.

Xinran Zhong (10:46):

And after all the design, the simulation and treatment, we also want to make sure we have mechanism to evaluate the in-act motion and try to correct any motion if we find any. So in total in our workflow, we would acquire three CBCTs for the motion evaluation. So the first CBCT would be used for the planning, which is a reference CBCT. And after the whole adaptive workflow and before the treatment starts, we would have the second CBCT and the motion between the first and second CBCT we name it the pre-treatment shift. And then in the middle of the treatment beam delivery, we would acquire another CBCT. That’s just to verify the intro fraction motion and the motion between the first and third CT, we call it intact shift. And this shift is more critical related to the patient’s safety and the beam delivery accuracy. And one thing to notice is that after the second CBCT shift, we usually need have to do a recapture. So we build a new surface with this CBCT verification.

Xinran Zhong (12:06):

So in our current data analysis we collected around 50 to 60 fractions for each group of patient. So we got around 50 fractions for breast patient, free breathing and breath hold. And for this patient group, the target would be the whole breast and the prescription would be 26 Gy in five fractions. So it’s very homogeneous. And for the lymphoma patients the treatment sites and the prescription dose would vary a little bit but we manage to collect enough fractions. So on the right is just an example of the target and the dose for each group of patient respectively. So on the top is the whole breast, and on the bottom is alymphoma case.

Xinran Zhong (12:59):

So then let’s take a look at our data analysis results. So first we analyze the motion for our breath-holding patients. And on the left is a histogram of the pretreatment shift. On the right is a histogram of the inter fraction shift. So as we can see in general, the intersection shift is shorter compared to the pretreatment shift. And this we believe is related to the time from the latest surface capture to the CBCT. And as we can see, like I put the time statistics, the pretreatment shift between the previous surface to the current CBCT, it’s an average 40 minutes, but before the inter-fraction shift, since we build a new surface in the second CBCT, like the time interval is shorter, so it’s on the order of six minutes. So since the inter shift is what we care more like, that’s more related to the patient safety and we found that only one fraction of the shift that’s more than our margin, that’s five millimeter and the motion is 5.2 millimeter.

Xinran Zhong (14:12):

And this corresponds well with our SGRT tolerance. So it shows that the motion that SGRT guidance is very effective for our whole breast treatment. And how about the time cost? So here I did a box plot comparing the free breathing patient group and the breath-hold patient group. So the setup time, which is includes a lot of other steps, but it’s a fair comparison. As we can see, the time are pretty comparable between the free breathing and breath hold patients. And the session time, which is from open the patient to close the patient, which corresponds to the machine time. It’s pretty also pretty similar, like the breath hole patients take slightly longer, but on average it’s only four minutes longer, which is pretty short compared to the whole session time.

Xinran Zhong (15:08):

So similarly, we did the comparison for the lymphoma patients. As we can seethe PTV margin is slightly larger due to our motion evaluation from the simulation. But we see similar trend, like we see much smaller intra-fraction shift compared to the pretreatment shift. And among all 65 fractions, we only see one fraction that’s with a shift that’s more than seven millimeters and the shift is eight millimeter. We also notice that the time bet between the latest surface capture and this CBCT is 60 minutes, which is much longer than our average. So this fraction could be due to some very special situation that patients just couldn’t do a very consistent breath hold. And we also correct the motion with the CBCT. So similarly, we also compare the time cost. So here we can see the beam delivery time with the breath hold is slightly like higher around about five minutes. And but we can see the session time at least the average are pretty close to each other. So which shows that the breath hold although it gives a longer beam delivery time, but you won’t necessarily add the machine time for our abdominal lymphoma patients.

Xinran Zhong (16:35):

So in summary, we demonstrate that patient education and motion evaluation during simulation are essential for our successful breath hold motion management workflow, which shows that the AlignRT InBore guided breath hold can provide reliable inter-fracture motion control for our whole breast and abdominal lymphoma patients. And we also show that although the breath hold could add some time cost for some steps of the workflow, but in general, the added time is pretty minimal compared to the overall session time. And in the end, we found that it’s, if we observe a significant time passed since the latest surface capture, it may be beneficial to verify the breath hole consistency using the Cone Beam CT in the middle of the beam delivery for safety purposes. So that’s it for my presentation, and I’d like to thank our great physicist team, physician team and therapy team. Without them, we can’t implement this. Thank you.

Tracy Reece, BSRT(T)
Oklahoma Proton Center

Helena White, RT(T)
Bryan Hammers, RT(T)
Oklahoma Proton Center

Wendy Tisue, MBA, RT(R)(T)
Mayo Clinic Cancer Center

Kiran Kumar, MD
University of Texas Southwestern

Video Transcript

Kiran Kumar (00:01):

So I am going to talk a little bit about something he touched upon, which is non-coplanar treatments, and specifically, from a clinician’s standpoint, when we think these are valuable how we can make a difference in patient care. And so see if I get this to work. Perfect.

Kiran Kumar (00:21):

So here’s kind of the basic outline for the next 15 minutes or so that I’ll be talking. And so I’m going to start off just talking a little bit about, you know, what Noncoplanar is and why we consider it. But I really think, at least from a physician’s standpoint, it’s most powerful to just go through some cases. I’ll talk about the literature and some of the studies that are published showing which cases benefit from Noncoplanar treatments, and then go through some illustrative examples. And then I’d like to end on, you know, kind of some of the reasons that we often don’t do Noncoplanar.

Kiran Kumar (00:51):

And so, you know, I think I’m talking to a room of physicists and therapists and a lot of people who know this much better than I do. But just in case you’re not familiar with what Noncoplanar treatments are. So Noncoplanar treatments use a number of fixed or rotating beams that don’t share the same geometric plane, right? And so the goal of this is all to reduce beam overlap away from the tumor. And this is something that, you know, we were doing a lot of but then as you know, arc therapy came along and VMAT, you know, these plans became pretty good without Noncoplanar treatments. And a lot of physicians and a lot of radiation oncology centers have kind of moved away due to some of the barriers, which I’ll talk about at the end.

Kiran Kumar (01:34):

But I think it’s kind of unfortunate because as you know, from the MD standpoint, you know, what I would encourage everyone is to not just do pretty good treatments, but try to do the best treatment for your patients. And there are a lot of times that you’ll see where using Noncoplanar, like a simple thing by adding one, you know Noncoplanar arc, for example, could make a dramatic difference in the plan quality could significantly reduce the dose to OARs and have a meaningful impact in the patient’s quality of life. And so I think now we have new technologies like MapRT, which you’re hearing about that make this a lot easier. There are new Linac that have come out now that allow automated motion. And so I think we’re going to see a big renewal from the community in using Noncoplanar treatments.

Kiran Kumar (02:21):

And so the big theme that you’ll hear about for me is, you know, Noncoplanar treatments are really allowing us to reduce the dose to nearby OARs not in every case, but there are a lot of cases where this makes a huge difference. And so I think most of us are familiar using this in SRS or SABR or SBRT but there are actually a lot of other situations where it could be significantly beneficial.

Kiran Kumar (02:50):

And so I’m going to go through I’m not going to touch on all the disease sites, but I’m kind of going to highlight some of the most common disease sites that we are using Noncoplanar treatments in. So head and neck is what I’m going to start with. And we are using it both for conventional and SABR head and neck treatments. Not every single one, but there are certain ones that will benefit. And so here’s a very interesting study that showed they kind of compared coplanar VMAT, Noncoplanar VMAT and found significant reduction to many OARs. And if you treat head and neck cancer and some of these numbers are dramatic. And so there was, you know, a three grade difference in parotid, a mean a four grade difference in larynx, a mean of five grade to the oral cavity and pharynx. These are really big numbers in the head and neck world. And they did some modeling that shows up to a two third decrease in normal tissue complication and a 25% potential decrease in local recurrence due to dose escalation that using Noncoplanar treatments can do.

Kiran Kumar (03:50):

Nd here’s another study. This was actually a prospective, it’s a small study. It’s a prospective phase two clinical trial of 15 patients who had recurrent head and neck cancer. So here’s one of the cases where we’re very stressed about the dose to OAR in these recurrent settings. And in all 15 of these patients, they actually had a coplanar plan, a noncoplanar plan, and the noncoplanar plan was chosen in every single one. And it found significantly improved dose conformity as well as a significant reduction in dose to these OAR. And I think you can just see this image on the top right kind of the difference in this dose that’s falling to the contralateral side of the tongue. The things that we care a lot about in terms of side effects.

Kiran Kumar (04:34):

Here’s a case that we treated at UT Southwestern. And this was a right posterior ethmoid neuroendocrine carcinoma. And on the left you’ll actually see this was initially started on our unity, which is our adaptive Mr. Linac. And so one of the things that, you know, at UT Southwestern, we’re very lucky, and I have a lot of our physicists here we have a lot of technology, right? We have a lot of toys to play with. And so we have these MR Linac’s we have our Ethos, our CT guided adaptive Linac, and this was attempted to be true on the Unity, but unfortunately, with some of these machines, right? You’re, you’re confined to coplanar treatments. And this was a patient of David Sheer, who’s the head of our head and neck, and he ended up switching off this due to the plan quality.

Kiran Kumar (05:21):

And you can see on the top left just how much dose is spreading left and right for this ethmoid sinus cancer. And then when we were able to do this on one of our other machines that allowed Noncoplanar, like you can see there’s two partial sagittal arcs there. We were able to bring these iso dose lines and, and keep the dose very sharp left and right.

Kiran Kumar (05:42):

And so I’m going to go to lymphoma. So I am a lymphoma, paediatrics, and sarcoma specialists. So this is something I know well. And lymphomas affect every part of the body. So we have NK T cell lymphomas, which I will always do Noncoplanar for the same reason as that example you just saw. But there is also a lot of times in lymphomas in the mediastinum. And so Matt talked about this a little bit, but this is extremely important.

Kiran Kumar (06:07):

So anyone who treats lymphoma knows that these patients are often young and they have excellent outcomes, right? The large majority are living long term. But the big problem with radiation and why, you know, so many of our medical oncology colleagues are trying to get rid of us is because they’re worried about these long-term effects. And specifically they’re worried about heart and they’re worried about secondary lin. See breast cancer. And so here’s a nice study that compared both coplanar, Noncoplanar, VMAT and coplanar IMRT with a variable number of beams and Noncoplanar IMRT with variable number of beams. And you can see here, you know, for both of these, the solid blue line is the Noncoplanar arc, which had significantly reduced heart dose and breast V four. So just with the breast, for those of you who don’t know, just any amount of breast tissue getting four gray or more has an increased risk of secondary malignancy. And so if you’re treating to 30 Gy or whatever we normally do for lymphoma, keeping the 4 Gy iso-dose line off the breast can be very, very challenging, right? And this graph shows how the more beams helps, especially if they’re Noncoplanar beams. And then obviously the Noncoplanar arc can make a big difference.

Kiran Kumar (07:16):

And I think seeing images for me is always better than looking at charts and numbers. And so here, you know, most people would probably treat this with VMAT, right? And so VMAT is the second box, but with VMAT you’re spreading dose kind of left, right? Right. The lungs, the breast, what I’m most concerned about there is the breast, right? If you look at the butterfly VMAT or the Noncoplanar with 15, you know, different angles of the IMRT that’s significantly sharper, keeping this dose anterior-posterior much better. And that is a huge difference in terms of long-term secondary malignancy risk.

Kiran Kumar (07:56):

Okay, so switching gears out of lymphoma to breast. And so breast cancer is another you know, site where people are trying different beam arrangements to see if you could reduce dose to the contralateral breast. It’s often most concerning in left side of breast cancer. And when you’re treating the IM nodes, so this was a study of 20 patients left-sided treating the IM nodes and they compared non-complaint or VMAT to co-plan or VMAT and 3D plans. And they showed that this non-coplanar VMAT has significantly reduced the dose to the heart and ipsilateral lung compared to coplanar and 3D, and also reduced the dose to contralateral breast and lung compared to coplanar. VMAT ended up being similar to 3D. And these numbers are meaningful, right? There’s a 28% reduction in mean heart dose, a 20% reduction in ipsilateral lung dose, a 53% improvement in the conformity index. So these plans are much more conformal. So this is very powerful, right? When, and a lot of times we’re doing this com comprehensive nodal radiation for these breast cancer patients. And just doing IMRT may not be enough if you’re doing coplanar IMRT. Okay, so the last few cases I want to show, so this is in lung cancer. So I think you know, most people who’ve done lung SBRT or SAB

R are very familiar with using coplanar and non-coplanar treatments. And so these are some studies showing how Noncoplanar partial arcs could significantly reduce the lung V20 which obviously is important for radiation pneumonitis risk, but also the max dose cord esophagus, large bronchus, aorta, and trachea.

Kiran Kumar (09:34):

And a lot of these, you know, especially at UT Southwestern, I’m sure a lot of institutions were coming back and retreat, right? People are getting more lung mets, you have to come back. And so these are very important not just for that plan, but for planning ahead. And the next case I have kind of illustrates this. So this is a 71-year-old who had a non-small cell lung cancer of the right upper lobe, which was treated and then had a recurrence about four years later and had two anterior nodules in the right upper lobe recur in the vicinity to where the primary tumor was. And so in this case, we did SBRT, we did 50 grade and five fractions, but we’re very, very concerned with the dose to all that long and near there as well as going into the major vessels and the heart, the contralateral side.

Kiran Kumar (10:19):

And so you could just see this plan using these Noncoplanar arcs, how tight and conformal these isod dose lines were. And this patient is now two years since the re-treatment. No toxicities from this has been disease free. The last site that I want to talk about is the CNS. So again, Matt talked a little bit about this. And so, you knowing hippocampal avoidance, but just in general, right, with any primary brain tumors using Noncoplanar, either VMAT or using Noncoplanar beams with IMRT can significantly reduce the dose to a lot of these structures we care about hippocampus, temporal lobes, cochlea, contralateral oar. And we had our own in-house study for hippocampal avoidance, whole brain led by a lot of our physicists and we studied coplanar versus Noncoplanar with the vertex arc and found, just like Matt showed in the other study, significant improvement in hippocampal sparing.

Kiran Kumar (11:13):

And you can see some of the numbers here complaining comparing the Noncoplanar to coplanar and its hippocampal, D100, D max, all of these were improved using the vertex arc. The maybe next to last case that I’m showing here. So this is something that’s near and dear to me. So I do lymphoma, and I also do pediatrics. So this is a study that looked at cranio PHNs, which you get in adults or kids. This had 10 patients and you can see from some of these images if you had just done this with either a conformal arc or a conformal VMA plan, trying to treat this cranio phenoma, but sparing the bilateral hippocampus, is very difficult. But these, this is not a malignancy, right? These are benign tumors. These kids are going to live long normal lives, but the radiation dose of the hippocampus is going to be what drives their long-term neurocognitive outcomes, their decreased iq, and decreased performance in school.

Kiran Kumar (12:08):

And so just a simple thing of using a non-coplanar arc in, instead of just doing coplanar reduce the dose to the bilateral hippocampi by 4 Gy. So from 10.8 Gy to 6.5 Gy. And if you look at the pediatric literature, 6 Gy or higher is where you get these long-term effects and every, and it’s not just the threshold, right? Every Gy, it’s kinda like the heart, like 6 Gy is better than 8 Gy, which is better than 12 Gy. Like every dose matters. And so this is pretty meaningful for, for these patients. And here’s another example. This is an older patient who had a malignant meningioma of the right frontal parietal region. And again, when you have especially these lateralized brain to tumor seven for fractionated treatment, this was 60 Gy 30 fractions using these Noncoplanar beams could significantly reduce the dose to the rest of the brain.

Kiran Kumar (12:59):

And so my last slide is on why non why, why not Noncoplanar? Sorry, double negative. And so, you know, many people, if you ask them, these are the common complaints, right? So treatment time is obviously the biggest and you know, and it’s not just the time for the patient by doing a couch kick or whatever, but all the physicists on here know and everyone else knows just the time for planning for dry runs. If something’s non-deliverable, the delays of, you know, replanning and repeat QA, all of these things. So that’s a problem, right? Fortunately, we have solutions the treatment time for the patient. And concern about infra fraction patient motion, concern about the delivery accuracy. And then finally collisions, right? Patient safety collisions. Anytime we’re doing these more complicated plans with a non-coplanar plane, that’s always a worry.

Kiran Kumar (13:53):

But, you know, I think the beauty is now with these novel technologies that we have, it really takes away a lot of these barriers. And so it’s more just, at least on the physician end, on the clinician end, we’re thinking. It’s not for every patient, it’s not for every treatment, but often you don’t realize until you try. And so this is my, I run the residency program, so this is my like, education hat. I always tell my residents, like, if you don’t even ask, no one’s going to do it, because it’s so much more work. Dosimetry is not just going to throw in a Noncoplanar arc if you don’t say anything, but if you bring it up and you actually ask and you say, let’s create two plans, let’s compare these. It may not be different, but it might be pretty significant. And these are things that people just don’t realize but can make a huge difference in patient care.

Mindy Joo, PhD, DABR
Inova Health

Video Transcript

Mindy Joo (00:04):

Good morning. Today I’m going to be presenting our initial clinical experiences with SGRT system. I’ll first give a brief background about our department at Innova Health and about the InBore SGRT system. I’ll talk about our SGRT workflow from CT simulation to treatment and finish with a couple patient treatment examples. So Inova is a health system located in Northern Virginia outside of DC. We have several hospital locations spread across the region. The Department of Radiation Oncology is part of the Schar Cancer Institute and has about five hospital locations across the system. We have 10 Linacs total. So that’s the C-arm as well as the ring Linacs. We also have speciality machines like CyberKnife, proton therapy, and extensive brachytherapy program. Currently, we have about 10 AlignRT systems, including eight C-arm systems for our photon therapy and proton therapy, or C Linacs and the proton therapy and to InBore SGRT systems for our health down and Ethos. So last year our Fairfax Medical campus got our Ethos. After all the commissioning and training, we went live treating patients in December of last year. We started with treating sites like the abdomen, pelvis, CNS, and extremities. Later on this year, we’ll be extending to other sites like the head and neck and lung. Within about one month of going live, we were treating more than 40 patients a day on that machine.

Mindy Joo (01:55):

So this is the InBore SGRT system for our Ethos, there are two sets of cameras. There are the ceiling mounting cameras you can see here, as well as the InBore ring cameras that you can’t really see in this from this picture. So the three external cameras are mounted on the ceiling, just like the c camera system. Those cameras point at the same Isocenter. And they’re usually used for initial patient setup. So once the therapist bring the patient in and put them on the couch, those cameras are used to position do the initial positioning for the patient. After that is done, the patient will be moved InBore for treatment positioning, and that’s where the InBore cameras come into play.

Mindy Joo (02:38):

So there are two cameras on the InBore ring and this ring can be removed using the knob on the bottom of the, the ring there. And those rings are used for patient monitoring during treatment delivery. I won’t be talking too much about the QA for the SGRT system.

Mindy Joo (02:55):

I just want to talk about bring up that the QA devices for the InBore system are the same as for the C-arm system. So there’s the play for daily QA and physics calibration, as well as the cube phantom. If you want to calibrate your MV Isocenter to the SGRT Isocenter.

Mindy Joo (03:18):

In terms of software interface, the invoice SGRT looks pretty much the same as the C-arm ones. So in the preparation page where a therapist usually import the patient, you can see like the plan, how the protocol and surface sets are laid out. It’s pretty much the same. In terms of treatment interface, the deltas are still displayed the same way. And on the top you can see what the plan and structures that you have there. One thing that is slightly different is on the bottom that you can see the setup and treatment options. So those are referring to the two sets of cameras for the InBore system. So the setup would be referring to the external three cameras in the ceiling for initial setup and the treatment are the ones inside the bore when the patient’s actually ready for treatment. Sothis allows the therapist to toggle between the two, depends on where the patient is and what you want to look at. Another difference with the InBore system is that it displays two sets. One is a set up Isocenter and one is a treatment Isocenter.

Mindy Joo (04:22):

And as I mentioned before, because of the two sets of cameras, the external ones are used for setup. So it looks at the setup Isocenter, and once the patient’s inside the bore, the InBore cameras will look at the uses, the treatment Isocenter.

Mindy Joo (04:37):

So our therapists have been active SGRT users for years. We use SGRT for about 90% of our patients from initial setup, DIBH to treatment monitoring. However, even with all these years of experience before our went live, our therapists were just having all these questions, like how are we going to deal with the two sets of cameras? How are they correlated? How are we going to set the patient up? Which one do we use? How do we move the patient while the patients are in the bore? I guess one of the most important question is like, do we need to change our workflow or make a special adjustment just because we have this import system?

Mindy Joo (05:21):

SoI wanted to talk about what our general workflow already is witchlike a TrueBeam SGRT system. So starting at CT simulation, patients are set up in a standardized setup with immobilization devices. At least one of the devices is indexed to the couch. Currently we still mark or tattoo our patients, so that would be done during CMT simulation. And then once the images are transferred to the treatment planning system dosimetrist will mark where those bb’s are. Set of localization point, we do have several TPSs. So we use RayStation and Eclipse. And now that we have Ethos, we also have the Ethos TPS. After the plan is complete and approved, we’ll be imported into the SGRT system and therapists will, you know, select their services and delineate their ROIs appropriately. And then at treatment delivery, patients will first be set up using the same devices, using the CT sim therapist will align the patient or the marks on the patient to the room laser. They’ll turn on the SGRT system, make any fine adjustments just according to what the SGRT system is telling them. And then once they’ll step out the room, make their imaging if needed and shifts and all that.

Mindy Joo (06:45):

So if we look at what our InBore workflow is like in terms of city simulation everything’s pretty much the same. We use the same devices set up positioning. Not much has changed per se. So therapists continue to place marks or tattoos andCT simulation. Once those are set during treatment planning, those dosimetrists will continue to set those localisation points. One thing is that localization point is going to be the setup Isocenter in SGRT. And once the dosimetrist make their plan, it depends on how, if there’s any delta shift between the bb’s and the fields. The field where the fields are, it’s going to be the treatment Isocenter. So once the plans are done, they’re exported from TPS to SGRT. Like I mentioned before, we do use multiple TPSs. So physics, we kind of check that all that information didn’t get lost while we’re doing all these transfers.

Mindy Joo (07:45):

And in terms of plan import into the SGRT system, it stays the same on the interface, is all pretty much the same. So we select which plans, which protocols and the structure set that the therapist would like to use. They will also draw the ROIs and the bottom image. I know I keep repeating this, but the main difference with the invoice SGRT system is that you will see the two Isocenters. So the gray one is the set up isocenter and the color of four one is the treatment Isocenter.

Mindy Joo (08:18):

For our InBore treatment workflow, therapists will first serve the patient using the marks and align those marks to the InBore laser. They will really focus on adjusting the pitch roll and rotation using the SGRT mainly because Ethos Couch has only three degrees of freedom. So the rest three degrees of freedom really rely on the therapist to manually adjust them before the patients send into the bore for treatment. So after that, they will move on to the translational deviations using SGRT and make adjustments. After all that is done outside the bore, the patient will be moved into the bore ready for imaging and treatment. And then at this time, therapists will change the SGRT camera from setup to treatment. The step out of the room acquire cone beam CT and make any imaging shifts accordingly. After that’s all done, they will take a new reference for this treatment session while the patient’s inside the bore.

Mindy Joo (09:23):

And now I’m going to just give a couple patient examples that we’ve encountered. So first one is a prostate patient here. Like many clinics out there, our therapists love the postural alignment feature of the SGRT system. So that’s like the first thing they turn on after patient’s on the couch. So first they use those three different cameras to get the patient to within those outline they will focus on the rotation role and pitch deviations first and really get those two as close to zero as possible. And then they’ll move on to the translational deviations.

Mindy Joo (09:58):

Another feature they like is this deformation. So it tells them exactly which part of the ROI they need to focus on to get that delta route close to zero. So instead of guessing like, oh, maybe patient needs to roll to the left, maybe the right hand needs to be up, you know, they can just look at this and be like, okay, mostly most of the deviations coming from the stomach, maybe patient’s a heavy belly breather and maybe we need to adjust the ROI. So it’s not just recording that.

Mindy Joo (10:28):

After all that adjustment is done outside the bore, patient is moving to the bore. And then on the bottom therapist will select the treatment cameras. So now we’re monitoring the patient inside the camera with those two cameras. One thing that is nice about the SGRT is that it gives the six degrees of motion while the patient’s inside the bore. Ethos does have a camera that will monitor the patient during treatment. However, that camera only gives us one directional shift. I think it’s lateral, so it doesn’t really give us that much information that helpful to us. So we actually have that turn off for our Ethos machine and we really use the InBore cameras to monitor the patient.

Mindy Joo (11:14):

After a cone beam CT is done for this patient and shifts were made, therapists took a new reference capture for this treatment while the patient’s inside the bore.

Mindy Joo (11:27):

One thing I wanted to talk about is the ROI selection. So, especially for pelvis and breast patients, there’s been different versions of ROIs out there. Currently, our patient’s therapists favorite one is the one in the middle. So that’s pretty much a similar ROI they draw for our C-arm TrueBeam patients. There will be other examples like the one on the left where the abdominal belt is like removed, so they were just focusing on the lateral hips. Sometimes for like patients who breathe really fast or something, that’s something that they might use to monitor patients then. Another variation is the one on the right where they really expand the ROI laterally and up around the hip. This one hasn’t been working for us as well because sometimes our hip patients or pelvis patient has fat lock backs around them in the pelvis region and the back actually goes high enough laterally to cover those parts of the body. So monitoring those parts not don’t really help us with setup or anything.

Mindy Joo (12:38):

So for this case the SGRT really helps us with pitch roll and rotation management. Since Ethos only has three good degrees of freedom, so this not only will reduce reimaging or any readjustment after a patient is like in the bore already and just hard for anyone to reach in and move the patient. ROI does play a very important role. So our therapists have like a preferred ROI, they like to draw that might work better for them or it might be patient specific that will really help them to position the patient. SGRT reduces overall setup time and also allows better patient monitoring during treatment delivery.

Mindy Joo (13:24):

The next example is a brain patient that we have. So for CNS and hand and neck patients, we use closed masks. And that kind of raises some questions because with closed masks, why are you really monitoring, why are you positioning, you’re the cameras are just looking at the mask. So then while we had our dosimetrist do is to ask them to control the patient without the mask so that when the therapists import all the DICOM info, we’ll have the surface with just the patient only without the mask on. So in this picture here, the patient was first set up on the table without any mask on. Therapists will select this patient only contour outline and use that to do initial adjustment. So they’ll use that to again, focus on the rotation roll and pitch like they will look at the screen and make sure that the chin is in the right, up or down or if the head is real to the left or right. And then after that, after the rotational, they will move on to the translational. And then at, at that point you’ll tell the patients, okay, we’re like, you’re aware, we want you to be, we’re going to put a mask on now.

Mindy Joo (14:41):

So that’s about the time when they put the mask on and translate the couch into the bore. Also, at this time they will change the treatment camera to change the camera to the treatment ones inside the bore. So with our hand and neck patients, the use of SGRT the use of multiple surfaces really help with initial patient setup because it allows us to use patient-only surfaces without any masks. SGRT also gives us less patient readjustment and reimaging after they’re in the bore.

Mindy Joo (15:16):

So overall our experience with InBore SGRT system has been a very high therapist satisfaction. There’s a reduction in setup time and reimaging dose. It also gives better patient motion monitoring while the beam is on. And that’s about it. Thank you.

Josh Naylor, MPE, MSc
University Hospitals Dorset

Video Transcript

Josh Naylor, MPE, MSc (00:00):

So, I’m going to be talking about latency. The title was there down at the bottom, right in Welsh. I’m not Welsh, but I had to go to Wales three times to get these measurements on the other vendor system. So that’s the explanation for that. And this was actually on those trips. So today I’m going to talk about what latency is and why it matters. Why should you care about it as much as I do what the latency is for a therapist if you don’t have SGRT or if you have beam hold switched off, how long it takes to, to kind of notice the patient’s moved. And then we’ll take a look at the manufacturer’s claims, the specifications from each of them, and the guidance documents that are available with tolerances and kinds of methods. Then I’ll talk about those methods that have been published and are available to us to use to measure latency. We’ll look at the results that I got from all of the major SGRT vendors, compare them and then consider the clinical significance of those results.

Josh Naylor, MPE, MSc (01:06):

So latency is the term that I tend to use, but in the literature, there’s a whole host of terms describing this. Some of them quite wordy. But basically, what we’re talking about with the type of latency that I’ve been measuring end to end is when the patient moves, how long does it take for the radiation to shut off? And why does it matter? Like, why do we need to do these measurements?

Josh Naylor, MPE, MSc (01:31):

So I think probably most of us here are physicists and there’s many therapists here as well. I feel that the reason we all are here is to ensure the right dose of radiation goes to the right place in the patient, right? And hits the tumor and not the healthy tissue around it. So we, all of our quality control tests and much of our treatment planning is focused on that, getting the right dose to the right place. So latency is affecting the positional aspect of that. So if the latency is too long, we’re going to be get delivering the dose to the wrong place in the patient.

Josh Naylor, MPE, MSc (02:08):

So, as I said before we had SGRT and if you have beam hold switched off on your SGRT system, the therapist is watching the patient. And if the patient moves that need to move probably a few centimetres to see it on the CCTV, there are all these processes in the brain that you have to go through to actually press off on the LINAC.

Josh Naylor, MPE, MSc (02:30):

And if you want to, you can dig out your phone and try that QR code there and measure your own reaction time. But here’s some data on kind of reaction times. The average is about 500 milliseconds, but actually it’s a really widespread, so for many people, maybe in a busy clinic, they’ve got a lot on their mind. It might may well take quite a lot longer than that 500 milliseconds.

Josh Naylor, MPE, MSc (02:54):

So yeah, the manufacturer specifications range from around that 500 mark all the way down to 50. Now that 50 is probably not right? Well, I’ll say probably it’s definitely not right. They, what they’ve done there is basically taken 20 frames per second, which Brain Lab can do, or they say they can do, and then divided one second by 20 frames per second to get that 50 milliseconds. So it’s not, not really comparable to the other ones.

Josh Naylor, MPE, MSc (03:26):

So yeah, just to illustrate this with some cheesy PowerPoint end-to-end latency. We’ve got the radiation on on the LINAC and the patient moves, the SGRT system detects that movement processes the signal, and when it exceeds the real time deltas, as they’re called in AlignRT, it holds the radiation on the LINAC and the LINAC itself has to go through some processing.

Josh Naylor, MPE, MSc (03:51):

So in this end-to-end latency, you’ve got that LINAC component. So to quantify that, I did the exact same method with the MV panel. I’ll come back to that method for RPM or RGSC, and that’s about 38 milliseconds on one of our LINAC. So that’s kind of as low as you could go. And of course, it’s more simplistic because it’s just one dimension. It’s not six degrees of freedom. But that’s kind of representative of that LINAC component.

Josh Naylor, MPE, MSc (04:20):

So in the guidance documents they’re basically mostly pretty vague. There’s, there’s not much help for using these about tolerances. TG142 quotes 100 milliseconds, and I just want to kind of emphasize that of expected, it’s got there. A lot of people have misread that. And there’s a number of peer-reviewed journal articles where people have said the tolerance is less than a hundred milliseconds and that’s mistaken it. So if it was 500 milliseconds, was your measurement at commissioning just to spell it out and really labor the point the your tolerance would be 400 to 600 milliseconds. So don’t make the same mistake. Lots of people in in the literature have.

Josh Naylor, MPE, MSc (05:05):

TG302 came along and reassuringly told us that latency measurements are challenging. That’s definitely true. And then they introduced some a little weight. I would say the tolerance is here less than a second for breast DIBH. And the 0.5 there is referenced back to TG76, but if you go back to that original reference, it’s actually talking about real-time tracking and the prediction models. So yeah, I wouldn’t pay too much heed to that.

Josh Naylor, MPE, MSc (05:37):

And I actually discussed with one of the authors of this document who also authored TG302, and she said that although they were released in the same year, this document is the one to rely on for the tolerances, for the numbers because TG302 actually took two or three years to go through the kind of peer review process. So this 200 milliseconds, it’s the first time in any kind of international guidance documents, we’ve had an absolute value rather than the 100 milliseconds of expected. And it does say for free breathing gating. So you might think, should we be applying that to non-gating? Just conventional SGRT. We’ll come back to that towards the end of this, towards the end of this presentation.

Josh Naylor, MPE, MSc (06:27):

So the methods, these are all published in various articles with more details on the method, but you can use a pin diode, Gafchromic film, I try and avoid that as much as possible, as it’s bit of a pain. And then there’s a really coarse one published that’s a stopwatch just being monitored with a video camera. Some centers have used scintillating crystals. I settled on the MV panel method and there’s a couple of publications on that.

Josh Naylor, MPE, MSc (06:58):

And then at this, this meeting two years ago in New York me and a colleague from Southampton Hospital just down the road from us, our kind of neighboring center, we worked quite hard on developing this MV panel method. So I’m not going to go into great detail about how we did the measurements, but you can go back and check out that talk if you want kind of a blow by blow on how to do a really kind of convenient method, cause it doesn’t require any additional equipment and it’s really reliable and I’ve, that’s what I’ve used for all of my measurements.

Josh Naylor, MPE, MSc (07:33):

So onto the results – I’ve done measurements for Elekta and Varian LINAC, done that for AlignRT and for C-RAD on, on both those LINAC. And then with AlignRT done those measurements for version six and version seven we’re on version seven right now.

Josh Naylor, MPE, MSc (07:53):

There was some nice improvements to latency. It got a bit quicker on version seven and I’ve done that for the region of interest, the conventional SGRT kind of set up and then the patch in the respiratory module for the free breathing gating and the patches slightly quicker. We’ll come back to that later. Also, identify from Varian Catalyst, C-RAD and then Brain Lab. So, nice spread of the, the major vendors.

Josh Naylor, MPE, MSc (08:23):

So the results, we’ve got them all here on one graph I’ll focus on them in turn, but you can see there’s quite a wide range and the manufacturer specs are there as well. Largely the end-to-end latency that I measured is a little bit bigger than the manufacturer spec. That’s to be expected because the manufacturer specification is not end-to-end, they normally state it for the SGRT system itself, which is reasonable because they don’t have any control over the LINAC side of things. So they’re saying what does the SGRT system add for latency?

Josh Naylor, MPE, MSc (09:04):

So just to touch on the Brain Lab one because this was done with a slightly different method by the team at Southampton Hospital. So using a pin diode, they actually got some of their electronic engineers to make that. I use the MV panel cause we don’t have as skilled and friendly electronic engineers as their team. But Brain Lab is up at two 60 or so milliseconds and using the same method as AlignRT systems that’s on Elekta LINAC. Both those103 milliseconds. So yeah, to come back to the MV panel method measurements that I’ve done, the AlignRT ones at my center, I’ve got kind of two or three years of annual QA across our four LINAC and then C-RAD I did on both Elekta and Varian at two different sites in Wales and Varian I did on two LINAC at one center. So they’re all TrueBeam except for that one that’s labeled the second bar on the chart. And you’ll probably immediately notice the massive discrepancy between the two C-RAD systems. Now that’s not because of the LINAC, that’s the obvious kind of first thought cause one’s Elekta, one’s Varian. But with a AlignRT we see no difference between Elekta and Varian and LINAC. So I chatted this over cause I was really confused about it. I thought, oh no, did I screw up the measurements on the variant one there with the six 30 milliseconds And I discussed it with a contact in Sweden who’s done a ton of work with C-RAD. Her PhD was using C-RAD for SGRT and her feeling is that it’s to do with the deformable algorithm, the registration algorithm at certain points C-RAD switches from rigid to deformable and the latency seems to potentially, these are all theories ’cause I was just discussing it with her on Monday. The latency seems to increase with the deformable algorithm. And then also there’s this feature called surface averaging in C-RAD and it basically averages the, it’s for breathing averages that breathing over the default setting is four seconds. So it’s actually looking at the previous four seconds and averaging out the breathing and that seems to add to the latency and it would seem that the 142nd value there on the electro LINAC for C-RAD, those parameters were not met. So the latency was a bit better. But yeah, Varian Identify it’s within the manufacturer specification, but it’s way up there compared to the 121 milliseconds on AlignRT. And we’ll look at the clinical significance of these measurements in a moment.

Josh Naylor, MPE, MSc (11:46):

So, one thing to also note on C-RAD, this is a screenshot from when I was doing the measurements, although on the Elekta LINAC we had quite a quick latency of about 140 milliseconds. The display you can see there where it says isocenter shift in the top right with the red and green graph, it actually takes a noticeable kind of few seconds to refresh. So your therapist might be sat there thinking, oh, they’re still intolerance, but it’s just because the graph hasn’t updated and there’s this kind of lag, but the radiation has shut off already. So it is a bit little strange when we were doing it was quite tricky to get the measurements.

Josh Naylor, MPE, MSc (12:27):

So yeah, the clinical impact is kind of the more important thing because it helps us put these measurements in context. So to look first of all at this for, I’ve used the example of SBRT lung because we’ve got that high dose rate. We use flattening filter free for all of our lung patients and thinking of free breathing or breath hold, we do a lot of both of those for our lung patients. So we will come back to gating with that TrueBeam flattening filter free dose rate. If you, this is just a really rough back at the envelope calculation. If you take the 200 milliseconds value from the ESTRO ACRO guidelines as a kind of reference of what latency could or should be and then work that through from the dose rate, you get eight monitor units delivered in that time when the patients moved out of tolerance and the beam should be shutting off. If it was perfect you’d get with zero milliseconds, which is obviously not possible, you’d get zero MU. So for our SABRE patients SBRT so many of them with the prescription schedule we have a thousand MU per day. So the 8 MU is 0.8% and taking the TG142 threshold someone referred to it yesterday as well, just that default, 2%, two millimeters. This would allow for two or three beam holds, 2.5 beam holds before you are starting to kind of exceed that 2% level. And that’s not many is it. We’ve all seen patients, I try and watch some to kind of keep a feel for what’s actually happening on the LINAC and plenty of patients move and have the beam gated that much. So if the latency’s less than 200 milliseconds, say a hundred, that’s then going to raise the ceiling of the number of beam holds you can have.

Josh Naylor, MPE, MSc (14:22):

So for DIBH breast more normal dose rates, not the flattening filter free. I looked at SimRT and kind of tried to assess this breath velocity. I couldn’t think of a better term for it. And how quickly the patient’s breathing out what they’ve got their breath held, how quickly do they, the return the surface returns back to the start position and it’s about four millimeters per second. So if we use again that kind of default TG142 threshold of two millimeters, the positional one this time that’s 500 milliseconds. And at a kind of normal treatment dose rate that would equate to five minus units incorrectly delivered. So for a conventional fractionation that we use 2.6 gray a day, and if a patient’s not terribly compliant, they’re not very good at holding their breath for the treatment, you could have up to 9% being in of the prescription being incorrectly delivered where they’re not at the exact breath hold. So if we take that 200 millisecond tolerance, again, this would allow for about 13 beam holds, which is you could see a patient get reaching that point within one day’s treatment especially if they’re struggling with the breath hold and it, if this is a whole breast PTV, it’s not quite so significant. But definitely if you’ve got a boost or nodal involvement, that’s going to have a bigger impact.

Josh Naylor, MPE, MSc (15:51):

So to come back to gating, we’ve been using the respiratory module from Vision RT since about February, I think this year.

Josh Naylor, MPE, MSc (15:58):

And a colleague of mine very kindly made me this lovely spreadsheet that lets you model the different parameters there and work out the clinical impact of the latency. So it has the inputs of amplitude, breaths per minute latency that you’ve measured for that machine or a tolerance just to simulate it at which phase of the breathing cycle you are interrupting the beam. And we used a few different waveforms. I’ve used Cos^4 here because it’s fairly realistic. A lot of publications have said that’s a good one to kind of model a human breathing.

Josh Naylor, MPE, MSc (16:31):

So it also has this nice pretty page to look at the tolerances that you need and you can put in different amplitudes of the breathing and different breath per minute. So I chose eight millimeters and 19 breaths a minute because this is the kind of worst case. It’s the for 90% of patients in, in the literature it says eight millimeters is the kind of the biggest amplitude you’d be getting. And then 19 breaths per minute is the fastest breathing. So the impact of latency will be worse for these patients. And if you enter those in, it shows you on the, where there’s the highlighted blue bar at which point at what latency level do we reach two millimeters of positional inaccuracy. So as the patient’s breathing when the beam they reach the gate where the beam should shut off, how with this latency of a hundred milliseconds there they will go just under two millimeters further. And the positional, the position won’t be quite right. So yeah, for these worst-case patients, this would suggest that our latency threshold should be less than a hundred milliseconds. So this is, I know I labored the point earlier about a hundred milliseconds from expected, but this is actually an absolute tolerance of a hundred milliseconds. And if we then go to a kind of best case where the amplitude is smaller, five millimeters any less than that and you probably wouldn’t want to bother doing gating, you could just do free breathing treatment. And the breath rate is then down slower at 12. That lets us kind of raise that ceiling of latency tolerance to 250 milliseconds. So you want to set your tolerances based on those worst-case patients of a hundred milliseconds. And I’ve got the results there in the corner from the respiratory module in AlignRT and then the C respiration module for catalyst the C-RAD system. And you’ll see that AlignRT is 84 milliseconds. So within the 100 milliseconds threshold.

Josh Naylor, MPE, MSc (18:51):

So just to kind of sum up and we might have time for a couple of questions. Latency really matters because it’s affecting the accuracy of treatment. So you should measure it and the tolerances, you can do those calculations for yourself and for different cohorts of patients. But I would suggest less than a hundred milliseconds for gated patients, otherwise less than 200 milliseconds for compliant patients. And do your latency measurements across all of your SGRT systems and LINAC and use them to inform your real-time Delta thresholds, because if your latency’s a bit longer you could reduce the RTD threshold and kind of compensate for that. Lower latency is always better. Vision RT has the lowest latency of any SGRT vendor and meets those thresholds that I calculated. Always use the auto beam hold. I said this in New York two years ago. Probably most of you are using that, but if you’re not, just go switch it on. There’s no point having SGRT. That might be a bit of an exaggeration, but I’ll stick with it. No point having it if you’re not got the auto beam, hold on because you’re then relying on the therapist to switch it off at the right moment. And yeah, definite thanks to my colleague who made the latency spreadsheet, Steve, the radiotherapy teams across the whole of Wales. And then Alex at Southampton who did, wrote all the code for analyzing the MV images and my email’s there. If anyone’s got question, you can ask now or during the break too.

Matthew Fraioli, RT(T), Stamford Health, Bennett Cancer Center
Jonathan Ortiz, MBA, BS, RT(T), Stamford Health, Bennett Cancer Center

Jonathan Ortiz, MBA, BS, RT(T)
Stamford Health, Bennett Cancer Center

Video Transcript

Jonathan Ortiz (00:04):

Okay, so as stated, this is about effectively transitioning to tattoo and mark free radiation therapy. You’ve already heard a lot about this from Justine and Emmy, so I’m just here to help any site that’s looking to do this can help make the transition.

Jonathan Ortiz (00:17):

So to be brief, introduction about where I work. So I work in Connecticut, which if you’re luckily enough to drive into, you’ll be greeted with this nice little sign. We are the self-appointed pizza capital of the country. I’m not saying I disagree a hundred percent with that, but it’s still a bold statement nonetheless.

Jonathan Ortiz (00:35):

So, our hospital is a 305 bed not-for-profit community teaching hospital. We have two TrueBeam’s. Unfortunately, we only have one AlignRT system at the moment, but Andy Klekar, if you’re around, I already asked what does the guy have to do to get our second one installed? Move us up the list. But so we are pending install of that second system. Once that second system is installed, we will be fully tattooless in markless. In the meantime, we’re tattooless, but we’re still doing marks, specifically for patients that have to be on the machine that doesn’t have a AlignRT. So that’s just a little picture of our cancer center. And we are a collaborative member of the Dana-Farber and Brigham Cancer Center. So we help share ideas and it really helps the community hospital, you know, really maintain that level of, integration and staying up to speed with the field.

Jonathan Ortiz (01:23):

So the agenda for today, we’ll be talking about what are some of the barriers to adoption of the tattooist markerless technique. Go through a basic workflow and the workflow adjustments necessary. Talk about the benefits over tattoo based setups and how do we ensure accuracy and reproducibility. And then troubleshooting, I had to take out, because it was a bit lengthy this talk, so hopefully some Q&A can help with that. And then some keys to be successful.

Jonathan Ortiz (01:49):

So what are the barriers? So I’ll explore each of these in depth more, but firstly I think is change. Tattoos and marks have been a part of our field for a very long time, and the idea of not having those can be a scary thought for some lack of experience, especially with the system itself. I think, there was someone who here who did a great talk last year about like, you can know how to use AlignRT but you don’t really know it. You know, you don’t really understand it fully enough to really embrace it. Comfort and familiarity, again, it goes back to that change aspect. You were comfortable with tattoos, we’re comfortable with marks. We can use AlignRT until something goes wrong. And then it’s like, now what? Now what do I do if I don’t know what to troubleshoot? And then the cost, which I’ll state it, we all know in this room it’s not cheap. So all the more reason to really in invest ourselves into it.

Jonathan Ortiz (02:36):

So firstly, I’ll discuss change tattoos. As I said, they have a long history in our field. They’ve been a vital part of the way we treat patients for many years. And it could take times for opinions to change. And with widespread adoption of new technologies, it really is incumbent upon those of us using it to really learn as much about it as we can to maximize its benefit. Many of us are so conditioned and used to tattoos, it does require sort of a reframing and a rethinking of patient setup. And not having a permanent mark to refer back to can make some uneasy. Because as we discussed earlier, what happens if the system goes down, which I’ll get to a little bit later. If not handled correctly, I think this can lead to some feelings of anxiety and making sure everyone is fully up to speed and is comfortable utilizing the system is important. If not, you can encounter some resistance. So as I mentioned, some rethinking, reframing no permanent reference point and if not handled correctly, can lead to some confusion, resistance, and in the end, change can be hard, but it doesn’t have to be. So my hope is that this talk helps anybody who’s looking to just take it that final mile.

Jonathan Ortiz (03:43):

Okay, so lack of experience. There is some, a little bit of a learning curve when you in first start incorporating this system. So that can be a challenge. Learning a new technique, new technology, figuring out how to adjust patients with this new technology and triangulate and angulate in a sort of a different way, without tattoos and deciding how to incorporate the technology into our practice. And this is an extremely important step to ensure everyone on the team feels comfortable. So it’s about how do we incorporate SGRT into our workflows? Not change them entirely, but how do we change the workflow itself around SGRT. Problem solving. That’s really what, when you start moving from knowing to really, truly understanding the system is you know how to troubleshoot. Something happens, you’re like, oh, I’ve seen this before, I know how to fix this. And problem solving, troubleshooting just two sides of the same coin.

Jonathan Ortiz (04:37):

So comfort and familiarity. So difficulties often arise when you first use the system and you’re encountering issues that you haven’t seen. For example, a lot of times what happens with breast patients is they’re swollen. So you’re seeing some, a lot of pitch issues that, pitch issues rotation role that you really don’t know how to correct. So like a really large role is an example of something that happened at a center I worked at where again, postural alignment, which you’ll hear me mention a lot in this talk, really helped us feel comfortable enough with the way we set her up in the room before we left, sort of ignoring the really large role that was like nine. And it turns out that’s because she had an expander that was sort of moving all over the breast. So we had to make an ROI that completely excluded that and we used that modified ROI for the rest of her treatments. So it does, some sometimes seem scary, like why is this happening? But I think when you see these issues more and more, you really learn how to troubleshoot them. And you know, like, okay, step one, I’m going to try this. Step two, I’m going to try that. And it really helps you get more comfortable with the system. So problems of this nature existed before we had SGRT, but with SGRT it makes them more apparent and we have to learn how to fix them.

Jonathan Ortiz (05:46):

The only way to overcome these is to determine sort of at the department level what the right course is going to be. And I think with this, which is what’s true with any new technology, is there’s going to be those naysayers in the beginning with experience. I think the more they use the system, the more they’re going to understand truly all the benefits it has, which I’ll explore in detail. And, they really learn how to maximize the system and its potential. And I feel SGRT is really one of those disruptive technologies in our field that has really drastically changed the way we look at setting up patients and especially how we monitor them throughout that treatment.

Jonathan Ortiz (06:21):

And then there’s cost. Anyone who’s been involved in these discussions knows it’s a pretty, pretty big sticker shock when you find out how much it costs. But I would say that makes it all the more, reason to really maximize its potential and not just use it for setup, not just use it for DIBH, but use it for everything. Use it for setup, use it for monitoring, and use it for every patient. And that really just helps maximize the investment in that technology.

Jonathan Ortiz (06:47):

So, a basic workflow and then how to make those adjustments when incorporating SGRT. So first step is always going to be prepare, prepare your patient if it’s a TrueBeam, prepare the beam, get your patient in the right position. And I would say at our center indexing is very important, especially as you’re starting to, what we’re doing in our department is limiting our mobilization. So not getting rid of it entirely, but that’s where the indexing really comes in handy. So you’re going to clinically straighten it, index your patient appropriately. This tells you that they’re in the right spot on that table so that when you do turn on the system, you’re not going to see something like that. So you see something like that, that should be jumping right at you and tell you they’re not in the right spot, I need to respond to that information. So in this case, you’re looking at that longitudinal value that tells you the patient needs to move towards the gantry. So while you could just move your whole table that way. You could be moving your table and then now you’re going to have a pitch that you didn’t have before. You might have a role that you didn’t have before. So this really helps is zero in on the patient position. And another thing we do at our center is we make sure that when before we leave that room, they’re set up to within one centimeter of those acquired couch values. So that sort of workflow we already have naturally makes sense with SGRT as you’re just making sure that before you leave that room, everything is as close to zero as you can get it. And we’re not just getting into the green. So if something like this were to happen, it could be our indexing, it could be the, in this case there was a backlog under the patient’s legs. It could be the backlog was in the wrong spot, we index in the wrong spot. And that’s why it’s important to respond to the information that the system’s giving you. Then you would just continue setting up your patient. And as a general rule of thumb, it’s good to start with your rotations, but if you do see something like what we just saw in that last picture, doesn’t mean you want to , you can’t just go back to the long fix and then go back to your rotations. There’s a lot of toggling back and forth. So often when new people, when I’m training new students or new therapists, that’s the one thing I’ll say is like, don’t get too rigid with how you approach the system. If you’re seeing something, respond to that first, then step into your adjusting your rotations, getting those close to zero and then transitioning over to your translations.

Jonathan Ortiz (08:58):

Then perform any pretreatment imaging, apply those shifts. And here’s another key difference is taking your reference capture. So depending on what that you want that reference capture to do, you either take it for this session only or you take it for this in future. And the only time we’re going to be taking it for this in future is if we want to negate or stop using our sim reference surface for setup and we want to transition over to this new reference surface. And I would say that happens very rarely. It’s typically in the case where a patient has had some significant surface changes between the sim and that time in treatment. An example that comes up is we had a patient, we were treating the, inguinal nodes and they lost quite a bit of weight. So we, the reference capture really helped limit the adjustments we had to make and gave us a more true representation of the patient’s surface. and then treat with intra fracture monitoring. So we also use beam control for every patient, different thresholds depending on what we’re treating. But again, it’s about maximizing this. Why should we be relying on manual beam hold when we have the system telling us the patient has moved?

Jonathan Ortiz (10:03):

Okay, so how do we incorporate SGRT? So this is obviously the biggest change, you know, it’s about how to deciding how and when it would enter the patient workflow, set a process. So as you’re making the transition, it’s often in conjunction with tattoos and it could be in conjunction with tattoos for a predefined amount of time. It could be, okay, we’re going to stop tattoo, but we’re just going to mark the patient. I think that’s something that should be determined at the department level. And it’s, I would say it’s based on the size of your department. So if you’re a larger institution, it might make sense to sort of stretch out that pilot period and maybe start one side at a time. But there’s value to either approach.

Jonathan Ortiz (10:43):

And I would say it’s time to start rethinking positioning and mobilization and it starts in the sim. You’ve heard that already today. And I think that’s always been true in our field, but even more so now. And it’s something that my colleague Matt and I will be talking about tomorrow. It’s about in your, when you’re in the sim it’s about how are we making this immobilization device with SGRT in mind? And how are we going to position this patient focus on the visibility for the cameras rather than truly immobilizing them. And it’s almost like using your mind’s eye where the cameras are in the room when you’re making that device.

Jonathan Ortiz (11:18):

Patient education, which is something we also heard about ready today. And I think the earlier you start this process, the better. Whether it’s in consult with the physician, whether it’s in the sim, we often do our education at our institution right before sim. So the patient kind of has an idea of what they’re about to step into. And I think it’s about explaining the reasons why or the why behind what we’re doing, especially when it leads means more what exposure for the patient. But the trade-off is we’re exposing you a little more, but it’s because we want the cameras to see. So we know that you’re in a position, we can confirm that you’re in the right position the entire time. So given that we’re asking our patient to be a little more physically exposed, I think it’s imperative that we explain the why behind it. And this is reinforced in sim, it’s reinforced at the first day or the verification simulation and throughout treatments.

Jonathan Ortiz (12:05):

Then here comes the downtime procedure. So it’s often not a very complex thing, but I think again, it starts in sim. So we also take our sim photos with the laser showing either our reference point or an ISO whatever, depending on what we did for that specific occasion. So we know, okay, if we don’t have an AlignRT which I’ll also add, I’ve been using it for six years, it’s happened once and it was a network issue, not Vision RT’s issue. So let the record show and it’s about, okay, we take our photos in the sim, here’s where the laser’s crossed. Okay, here’s the patient in front of me on the table, we’re in a good spot. Now I look at my indexing. Is my indexing appropriate? Is my patient clinically straight? Okay, let’s step out of the room and take our images because in the end we usually rely on internal imaging anyway. So that wouldn’t really change. We may get some larger shifts than we expect, but we would then involve the physicians, make sure the physician can review that image and decide what patients we’re going to treat during that downtime and which patients we wouldn’t. The ones that I would say for our specific center we wouldn’t be able to treat would be like a breath hold. But I hope that Vision RT stays true to its 99.9% uptime and we never have to encounter that issue.

Jonathan Ortiz (13:15):

And then, kind of show a little bit of this patient that shall not be named getting set up in a mask. can we play that video? So when you turn on the system, it’s often good to wait until your patient is in set in the setup position. The more you have the system on, the more data it creates, the slower your system becomes. So it’s about, again, you see my colleague here is pointing to those rotations, making those adjustments, fine-tuning those. And now there are some variables you can go through here. You’ll see the, the student actually who’s setting me up really got those down to as close to zero. Then put the mask on. You can sort of do an approach where you get them very close, put the mask on, but don’t put it all the way down. Make those final adjustments, then, attach it to whatever board you’re using. So customization, you know, depending on what your workflow is, is always advised. You don’t have to be so rigid with how you set things up. But the idea is you want those rotations like that, that’s a plus. And then you would make those final adjustments on the translations before starting your pretreatment imaging. So I’ll, I think you guys get the idea.

Jonathan Ortiz (14:24):

So one of the things that our Clin app who I know is not here, but shout outs to Kaitlyn Croy told us is that the earlier you start the monitoring, the more data it eats up on the system, which leads to more sort of freezing or any kind of glitches with the system. So she encouraged us to not hit play until the patient’s in position. And I would tell you it’s made a huge difference. We hardly ever have to deal with freezing or interruptions mid-treatment since we started doing that. So I highly recommend it.

Jonathan Ortiz (15:01):

Okay, so benefits over tattoo based setups. Firstly, would be accuracy. I’ll explain more of these in detail then would be safety, which is really how you get this, technology sold to the bore is patient safety. Efficiency, again, as Emmy mentioned and Justine mentioned, I think as therapists specifically, so much of our day is about how do I be more efficient than I was yesterday? So I think that’s something that this system really helps provide. Simplicity, using AlignRT can allow you to implement a simpler process, less shifting, less adjustments, less three points, then shift to an iso. All of that becomes sort of moot once you have this system. And then patient satisfaction and, something that I can’t go in depth too much to it today, but there’s some challenging setups that I’ve encountered that I felt like without SGRT, I don’t honestly think I would’ve, we would’ve been able to treat these patients.

Jonathan Ortiz (15:56):

So firstly, accuracy. So there’s just so much more information with AlignRT just as and as a point of example, it’s 20,000 points versus three. There’s just so much more information for you to use and to help refine your setup. And then postural alignment. I also want to know when did it change the Postural Video? Can anyone in here tell me? No? Okay, we’ll stick with the alignment then. The idea behind that, as we all know, those of you who don’t have it, I can’t say enough about it, buy it yesterday, you or have the ability to monitor the patient’s entire position. So you’re not just relying on your region of interest, you’re using it as a supplement and often you’re using it because your ROI is giving you some funky information and you’re like, but my postural alignment looks really good, so I’m going to continue on with this or I’m going to make an adjustment to my ROI until they both agree. So an example would be monitoring the patient’s chin position, especially when you’re treating nodes. It could be tracking the bolus position during treatment to make sure it doesn’t fall off or it’s in the right position. It could be something as simple as your CCTV goes out and you have no those three extra cameras in the room that you can monitor the patient with. And what it really helps is just refine your setup. Another example is at a center I worked at, we had a F head holder instead of a C. And by looking at the chin position, we were able to identify that. Another example was the, patient’s, apex of his lung wasn’t in the right spot because we were in the wrong indexing position. So all of these things are the information that the system gives you and I can’t talk enough about how good the system is for extremities, especially anything like a femur or humerus. It just really helps with those setups, as we all know can be truly, truly complex. Then surface deformation is something, I have a couple of slides on later, but it, it’s a tool that I never used too much until again Caitlin started showing me some ways that we can use it and to really identify the surface changes and sort of like carve out those on our ROI. Okay, and then 3D photos are another really nice feature that I have some slides about. So the 3D photo and the next, the another feature they have which is ROI metrics are sort of supplement to the postal alignment. While I would say postural alignment is one, the other two are one A and one B, they are supplementary, complimentary nature. But I think if you were to get just one postal alignment.

Jonathan Ortiz (18:26):

So the safety aspect, so you’re always setting up at your isocenter, this is one of those really key safety features that I think we often goes overlooked. There’s no separate three-point triangulation shift to an iso. It eliminates that possibility of error. There’s no shifting in the wrong direction, there’s no error in writing down the shifts and transposing them and executing them incorrectly. No more, as I said, no more incorrect shift, no wrong direction. Throw away those sticky notes that he bring into the room. Get rid of them, we don’t need THem. Patient movement, I often like to say that AlignRT is like the great un blinking eye in the sky, the therapist that never looks away, it’s that independent observer. Often as I believe Emmy or Justine mentioned, we are walking out the room, the patient moves a little bit thinking we’re not looking or they cough or something happens. We take our images and we’re like hmm, they set up really well in the room, what happened? We can now see if they’ve moved, we can adjust for it or we can feel confident that they move but settled right back into place. And I think that’s something that again often goes overlooked. There are often patients that are DIBH and they really struggle and they can drift outta position midway through the treatment. We can see that incorrect, and I think this safety aspect can’t be stressed enough with the increased responsibility on RTTs these days that we’re a compromising patient, treatment quality by not seeing and adjusting for this movement.

Jonathan Ortiz (19:49):

Efficiency. So what I think AlignRT gives us is faster and easier setups. We don’t need to adjust our pelvis patients specifically prostate patients nearly as much as we used to. So I’ve been at Stanford Health now for going on four months and that was one of the first things that we implemented was how do we use it for pelvis patients. And I think it’s really just led to a lot less manual manipulation of the patient, a lot less stress on our backs, moving them all over the place. And we often find that patients tend to sort of just lay in the general right position and just takes a little bit of fine tuning. We don’t need to hyperfocus anymore on the align to just three points and spend so much time getting those three points on. Less wasted movement built in SSD feature. I don’t know if you guys know about this one but it’s pretty nice. So if you are at a center that likes to cut these weekly or on the first day you get your patient set up and by the click of a button you can get all this information and as I mentioned earlier, but bears repeating extremities, whether the patient is frog left or I even treated this with the cubitus breast. Anyone can tell you those are very difficult. But with postural alignment specifically it makes those just as easy as the next.

Jonathan Ortiz (20:56):

And then onto simplicity. So a simplified process is a is available to us with less margin forever. Just simplicity is best. You have the ability to adjust patients and more emphasis on comfort and still maintain your accuracy. You can add certain things to the setup without compromising your accuracy because when you add it, you could see if it affected your setup. So if a patient is complaining that their back hurts a little bit, you can give them a little something and say okay, it didn’t mess anything up, we can, we can give you that. And it just really allows us to develop a more comfortable setup that’s still reproducible. So for example, I worked at a center that was going through a CT SIM replacement and not for all the patients but for some we were able to sim patients that had no bbs, no point of reference, no shift sheet, whatever it was. We just had a scan and a surface and that’s all we needed. And I think that’s that confidence that this gives you is that if I have a surface I can treat that patient. Another case was a loss backlog, another case was a deflated backlog. Both of those times there was no re sim needed and we were able to just reproduce that patient set up with our AlignRT system and it just leads to a much more streamlined approach.

Jonathan Ortiz (22:09):

So what tattoos and mark-less means is no more finding small tattoos, which I was guilty of. I’ll be honest, I made some very small tattoos so I was often yelled at for that. No more losing marks. So this still happens at our center because I know we, as I mentioned, we do still use marks, but one particular example that jumps out at me is a prone breast patient took off all the marks. We’re not going to get into why she did that, but she did and we were able to set that patient up on our AlignRT system, which at the moment we’re not using for prone breast only because of the way our patient population is divided up among machines. But we all were like, oh let’s just put it on our AlignRT and we’ll set her up and then we’ll give new marks for the other machine. So that’s the type of thing that this system gives you. And another thing that I have worked at institution where there was often lots of re-treatment with multiple tattoos. So I don’t know if you’ve been lucky enough to work at centers where it’s two tattoos, three tattoos, four tattoos. This really leads to no confusion with that and we don’t have to worry about that as therapists anymore when we walk into a room and great, the patient has no marks. Now what, alright, how many more patients we got coming or I’m gonna need you to call the one, the one 15, the one 30, ask them to come later. We don’t have to do that anymore. There’s no mixing up colors anymore. Whether it’s cone down primary first cone down, cone down, we don’t have to worry about that anymore. There’s no, even when you’re treating close to a prior site, we can still maintain that level of accuracy that we need.

Jonathan Ortiz (23:31):

So patient satisfaction, I think this was touched on already but again is worth mentioning again, what it gives us is less stress and anxiety for the patient. I often find that comes before they even enter our department, it’s about the discomfort they’re going to experience the increased emotional burden of this diagnosis, the permanent reminder of their, their journey in the lead up in simulation. I’ve had some patients cry when it’s time to get the tattoo and we always had to be in that awkward position of explaining or sort of encouraging them to get it and then stressing them out about like, well it’s going to stay there forever but maybe it’ll fade and we don’t have to worry about that anymore. I think what it also gives us is less stress about the patient maintaining those marks throughout treatment, especially on those hot summer days. And I think it gives us improved patient comfort. So it provides the patients that sense of ease and assurance that they’ll be treated correctly no matter what happens on that table. If they cough, if they move by accident, if they fall asleep and they, they jostle themselves awake, we can see everything and which is what I tell them as a warning, we can see everything. So even if they move inadvertently or cough or sneeze, we know immediately we can either confirm they’re still in the right position or we can correct their position. And then what it gives us is immobilization. Those considerations have changed now and less is more. We can make our patients more comfortable and thus less likely to move. If they’re claustrophobic, we can give them open masks, which leads to what I like to say is more of an passive way of immobilizing rather than active and not so much restricting movement but just helping them maintain that position. And open face masks, which I just mentioned is one of the major benefits and that’s where I think we see the most patients be really concerned and anxious about. And having that open face mask really limits that. And we can now in the sim focus on reproducibility and visibility for the cameras and not so much on immobilizing patients anymore.

Jonathan Ortiz (25:26):

So those challenging setups that I mentioned, one was an extended distance femur that the SGRT system really helped streamline the cubitus breast boost and some truly complex patient positioning. I’ll throw this up there, for you. But these two patients could not lay flat for treatment. They were in a sort of a semi seated, semi-supine position and there was, I can confidently say no way we would’ve reproduced these two positions without AlignRT. And I think it just gave us the confidence that despite what walks through those doors in our clinic, we can set that patient up and deliver that treatment and not have to send them away.

Jonathan Ortiz (26:05):

So how do we ensure our accuracy and reproducibility? So I think what the buzzword is at these conferences and especially today is ROIs. I think this is the single most important thing in this system, is creating ROIs that are reflective of the area that we’re treating and continually optimize those ROIs. I always tell, anyone I’m working with don’t get married to the first region of interest you draw, you can adjust those on the fly as much as necessary based on the information that it’s showing you. So sometimes it could be a poorly drawn ROI or it was placed over something that’s not patient anatomy. It’s drawn over an obstruction, it’s drawn in an area that the camera can’t see, it’s not on a blanket. For example, once the ROI is drawn, it can be modified so don’t stick with the first one, adjust as necessary.

Jonathan Ortiz (26:53):

Then I would say is respond to the information that the system’s giving you. And if your ROI is jumpy or unstable, if you’re finding the in room setup is not yielding the results you want, especially on internal imaging, it’s time to look at your region of interest. Then reference captures. So those break down into two different ones, which I think I mentioned already, but it’s this session only, this and future. If you find your setup with the CT SIM surface is not yielding the accurate results that you want with consistent shifts, then it’s time to think about, okay, maybe I need to set up on a good day and capture that new reference and then save that one for this in future sessions. And then these features that I think are really beneficial in maintaining or that level of accuracy is postal alignment one, number one. Then ROI metrics is a really cool feature that I’ve worked with before. So it sort of gives you that immediate response about the ROI you’re drawing and whether it’s too small, too large, too flat and there’s not enough topography and you can modify it right then and there when you’re importing the patient rather than waiting to see what happens when the patient’s already on the table. Then Surface Deformation. So that’s something I’ve been really trying to tinker around with now how to use that. And the 3D photo, which is sort of a really, really high definition picture of when you take that in-room reference capture. And I would say the most common utilization is on an SRS case where you really want to , might make sure your ROI is big enough and is not over the mask.

Jonathan Ortiz (28:19):

So Postural Alignment. So again, I’m going to really beat this horse. It allows us to provide that real time feedback utilizing that high quality live video and adjust the patient’s body position in real time and correct for that posture. Then the ROI metrics helps us draw those ROIs and get immediate feedback concerning the topography size and accurately monitor our patient. And then surface deformation, it helps us visualize any variation in the surface delineate areas of the surface changes and make adjustments based off of that information. So the most common example is like breast swelling or it could be your knee roll is too high and it would help identify that specific spot that is, that needs to be adjusted. So I would say each one of these alone is really beneficial and critical and they’re complimentary. But number one is Postural Alignment. And the 3D photo is, as I said, it’s that highly detailed image in the room and helps you clearly identify patient anatomy versus other obstructions. So you might’ve seen this next video before, but for those that don’t have postural alignment you can raise your hand in shame. It’s okay, it’s okay. This really is just a nice video that shows you what it gives you and how the regions of interest change based off of the changes in the patient’s overall position rather than just what the region of interest is showing you. So credit to Vision RT, this is on their website so feel free to, there’s a lot of good stuff on there.

Jonathan Ortiz (29:44):

So then ROI metrics. So this is what it looks like. We’ll be lucky enough to get this on our new system and then maybe we’ll be good enough at explaining to the board why we should have it on our other one. But what it does is you draw your region of interest and it gives that little blurb, okay, and this case I definitely cannot read that, but it might say this is too flat for accurate monitoring. Then you would go back in and adjust until you get two green checks and two green checks tell you good to go, you’re good to go. Two green checks means it’s a good size, it’s got good topography for accurate monitoring. If not, you’ll see those two error messages there. It may be too flat or it may result in slow monitoring if it’s too, too large and it may give you poor performance if it’s too small.

Jonathan Ortiz (30:29):

So this is the surfaced formation slide that I found really helpful. Again, a lot of this comes from Vision RT but the top right corner was sort of something that Kaitlyn showed me where you use the surface deformation with a treatment capture. So it overlays all the surface changes over the entirety of that patient scan. So you can truly identify where the adjustments need to be made.

Jonathan Ortiz (30:53):

And then 3D photo really gets you to see me in high detail. So there’s a comparison of what you’ll see, with 3D photo versus the standard reference capture. So it is very highly detailed and I would say the most, common use is when we’re doing SRS and you’re dealing with those really small, region of interest, often with, couch kicks that can lead to some camera obstruction. So the detail is really, really beneficial.

Jonathan Ortiz (31:21):

So, troubleshooting, do I have time for that? Maybe I’ll skip through this quickly. Jumpy dial says error messages bolus. Okay. Sorry. Oh wait, there it is. This is where I needed to be. Okay.

Jonathan Ortiz (31:39):

Keys to being successful. Training is the number one thing. Make sure your staff is adequately trained and comfortable before making that transition. I would say it’s good to sort of have a pilot, whether that means we’re going to pilot for all sites for three months, then remove the tattoos or we’re going to go site by site. Again, that should be determined at your department level and it’s about getting the buy-in and support, especially from administration, your physicians physics and dosimetry that really helps everyone feel like they’re adequately supported to make this this endeavor. Then it’s good to formulate some sort of implementation plan. You know, as for a department like ours that is sort of smaller, this becomes easierbecause you can get everyone in the same room at the same time, but having at least a well thought out roadmap of how you get there is important.

Jonathan Ortiz (32:26):

So training, so proper training is a must. This is a complex system that if not used properly can lead to really frustration and lead to a lot of places saying, oh, we tried AlignRT, we’re not going to use that. It doesn’t work. So the training from Vision RT is broken up into three phases, as many of you know we’ll be getting this with our new system. But phase one is sort of that, that first training, whether it’s at their Vision RT Center or in your clinic, where you get the high level view of what the system is. Then it leads into phase two where you get those webinars and everyone gets to get the same level of training and be prepared for the onsite visit, which is when the, the Clin App comes on site for at least two, two or three days while you’re implementing the system.

Jonathan Ortiz (33:08):

Then you could identify your super users. Again at a small start like ours, I want all of our staff to feel like super users, but at a larger institution it’s good to have those go-to people for the staff to really go to with questions and for troubleshooting help. And they can act as those in-house experts, especially when the Clin App leaves. They don’t feel like they’ve been abandoned. And it’s good to have those clin apps on site during that go-live. Whether it’s go live with the new system or go live with the tattoos and mark list. It’s really helps to everyone to feel comfortable with that transition. And the ongoing, support provided by Vision RT. We take advantage of this annual training. I know some of you may be taking advantage by coming here, but the support from Vision RT has always been there and I think that’s what puts them above and beyond the rest in this space is the customer support is always very quick and very detailed no matter what it is that you’re encountering. And then attending community meetings like this and presentations at, you know, the SGRT conference and really helping to tinker at the margins with what we’re using SGRT for and really unlocking its full potential.

Jonathan Ortiz (34:15):

Then that pilot project again, so it could be slow incorporation of SGRT, it could be one site at a time. You could set up as normal with tattoos and then implement SGRT. I will say that does add a little bit of time, but it’s about what makes the most sense for your center to get accustomed to the system and gain the confidence and experience that you need. Then expand its utilization to include more treatment sites if that’s the route you go. There’s also the rip the band aid off approach. So it really just, it’s about what works for your team. I think ultimately the right approach needs to be determined with all those parties involved. It could be the all in approach. It could be the camera’s not working approach.

Jonathan Ortiz (34:55):

It’s the buy-in and support that I mentioned earlier. So it’s important for the staff that they feel that support before they continue on with this, this implementation. They need to know the organization is committed to the technology they’ve bought into its utilization. They see the reason why we want to utilize it. I think often us as therapists are the biggest champions of this technology and it’s incumbent upon us to explain that, why we need that support. So we feel like we can continue utilizing it. SGRT systems, as I mentioned earlier, are not cheap. So it makes it even more important that we maximize the investment that the organization has made in this technology and not just use it for DIBH. We want to embrace it in order to have an effective rollout. So that buy-in and support should be from therapists first and foremost. Then it should be from leadership physics to symmetry physicians. Everyone needs to be on board.

Jonathan Ortiz (35:47):

And then, so some suggestions I would say that have worked in my experience. So I come from a center that was tattoos and Marks, I helped spearhead that effort. And now where I, at Stanford, I’m helping push us towards that as soon as we get our, our second system. So again, this depends on the size of your center, but you can formulate sort of a team, multidisciplinary team that can discuss the implementation plan before widespread adoption. You can formulate an SGRT committee and have all roles represented on that to discuss the right course of action. You want to establish those SOPs and protocols and this steps becomes even more important with a larger institution, regional cross coverage and traveling staff. As is becoming the norm. As these institutions get larger and larger, you want to reassess and revise everything that has to do with this. It could be the policies, it could be the regions of interest, it could be the protocols. You want to continuously evaluate those to make sure they’re working and they make sense. Again, just like you don’t want to get married to that first ROI, you don’t want to get married to the first thing you had before you started this program. You want to learn, you want to really implement the lessons learned. So as you build trust with the system, there may be some initial hesitation, but it makes it more important to truly demonstrate the value with the set, increased setup accuracy, the errors that are being caught, the image matching improvements and the decreased treatment times. Continuously evaluate your regions of interest, your workflows, your protocols as I mentioned. You know, don’t just stick with the first thing you decide upon. And then lastly, but not lastly, it’s collaborate with those Vision RT clin apps. They’ve been really helpful for me as I’ve really helped incorporate this system at now two different locations to help reinforce either what I’m saying or maybe fill in any gaps that I may have as we incorporate new things that we haven’t seen before at the center. And I would say again, a shout out goes to, Caitlin as a previous center I worked at, she was really instrumental in helping us with our first, prone breast that came across and really got us in a really good place for something that we didn’t do all that often.

Jonathan Ortiz (37:46):

So in the end, if I do nothing else today, if I can get everyone in this room from here to here, that’s a win. So in summary, tattoo and mark-free treatments with AlignRT can be utilized for both set up and motion management for any treatment site. Submillimeter accuracy in any treatment position, it offers us the potential to have faster, more accurate treatments, assist with highly complex patient setups, and with proper training and support, any size radiation oncology center can transition successfully. SGRT is, I believe, becoming the standard of care in radiation oncology and tattoo and mark free treatments are just the next step in that evolution. So thank you.