Accuracy and Time Savings of Tattooless DIBH Breast Setups Our Five-Year Experience

Margaret Barker,
MS Medical Physicist, MemorialCare Todd Cancer Institute

1. Presentation Title1

2. Accuracy and Time Savings of
Tattooless DIBH Breast Setups:
Our Five-Year Experience

3. 3
Accuracy and Time Savings of Tattooless DIBH Breast Setups:
Our Five-Year Experience
Disclosures
•I have no financial interests or disclosures
•I received a travel honorarium to present today
•This presentation is a collection of protocols, studies, white papers, data,
opinions, and anecdotes
•The information in this is not intended to endorse a specific product or solution

4. Accuracy and Time Savings of Tattooless DIBH Breast Setups:
Our Five-Year Experience
4
Learning Objectives
At the end of this presentation, the viewer will be able to:
•Explore the feasibility of SGRT for tattooless DIBH breast treatments
•Examine the time-savings of SGRT on tattooless DIBH breast setups
•Evaluate the accuracy and dosimetric impact of eliminating tattoos for DIBH
breast patients
•Recommend SGRT workflows for tattooless DIBH treatments for their own
facility

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Accuracy and Time Savings of Tattooless DIBH Breast Setups:
The Patient Experience
Background:
•Marks, wires, tattoos make it easier
to discern landmarks, surgical
changes, reproduce setups
•A typical tattoo setup scheme
needs at least 3 to establish a plane
to determine rotation
•Plus one straightener would be ideal?
•Plus isocenter tattoo?
•Plus boost tattoo?

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Accuracy and Time Savings of Tattooless DIBH Breast Setups:
The Patient Experience
Advantages to Eliminating Tattoos
•Reduced risks associated with sharps handling
•Reduced risks of infection
•No searching for marks
•No reproducing marks that fell off
•No extra consent for tattoos
•Patients are beginning to ask about tattooless treatments
•Patients do their own online research
•Patients compare treatments at survivorship groups
•No couch shifts

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Tattooless DIBH Breast Treatments Using SGRT:
Resources
https://www.saferradiationtherapy.com/cancer-treatment-center/
Online resource for patients
(and providers) sponsored by
AlignRT
-- AlignRT center
-- Tattooless
20-mile radius

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Tattooless DIBH Breast Treatments Using SGRT:
Rationale
RO-ILS THEMED REPORT:
DOSIMETRICALLY IMPACTFUL EVENTS
Examined trends related to dosimetrically impactful* safety
events that affected patients between January 2014 and
June 2023.
*Dosimetrically impactful = delivered dose > 5%, or OARs
received more than intended and exceeded tolerance
levels
SGRT can catch errors during setup before images are
acquired, eliminating the need to rely on imaging for setup

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Tattooless DIBH Breast Treatments Using SGRT:
Rationale
Abdomen
Bone
Brain
Breast
GU
GYN
H&N
Lung
Lymphoma
Pediatric
Pelvis
Skin
Breast 39%

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Tattooless DIBH Breast Treatments Using SGRT
Plans Sampled

11. Accuracy and Time Savings of Tattooless DIBH Breast Setups:
Our Equipment
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We have 4 separate systems to aid
with patient setup:
•BRAINLAB EXACTRAC DYNAMIC SYSTEM
•VARIAN RPM SYSTEM
•LASERS
•VISIONRT ALIGNRT CAMERAS

12. Accuracy and Time Savings of Tattooless DIBH Breast Setups:
Our Equipment (DIBH-Specific)
12
An entirely non-invasive and contact-free technology, AlignRTuses 3D stereo cameras to track the skin's surface and compare it to the ideal position in the treatment plan with submillimetric accuracy.
Each camera unit uses a projector and image sensors to create a 3D surface model of the area by projecting a red light (containing a speckle pattern) on the skin. The speckled pattern allows AlignRT to reference thousands of points on the skin, acting as virtual tattoos.
Known signal pattern goes out è Distorted signal pattern detected by camera è Reconstruction of surface

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Tattooless DIBH Breast Treatments Using SGRT
Supine Breast Treatments
Tattoo DIBH Left Breast Setup:
•Supine
•Wires:
•Scar
•Breast borders
•Arms abducted and externally rotated
•Slight incline if necessary
•Head turned toward contralateral breast
•Upper vac bag

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Tattooless DIBH Breast Treatments Using SGRT
Supine Breast Treatments
Tattooless DIBH Left Breast Setup:
•Supine
•Wires:
•Scar
•Breast borders
•Arms abducted and externally rotated
•Slight incline if necessary
•Head turned toward contralateral breast
•Upper vac bag

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Tattooless DIBH Breast Treatments Using SGRT
Ensuring a Robust Setup for Daily Success
Using SGRT for Setup:
Things to consider:
•ROI selection is crucial
•Should represent treatment area
•Contain topographic landmarks to ensure a unique solution
•ROI sufficiently large to prevent occlusion by gantry
•ROI sufficiently small to prevent loss in temporal resolution
•Will ultimately differ slightly per patient based on their anatomy
•Surface ROI needs to be correlated to internal structures via imaging
•Ground truth reference
•Treatment area-dependent

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Tattooless DIBH Breast Treatments Using SGRT
Impact on Treatment Times -- Tangents
Moderate reduction in daily setup time,
an average of 1-minute reduction in daily
treatment time. (p < 0.01)
Significant reduction in first day time, ~ 3
minutes. (p < 0.01)

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Tattooless DIBH Breast Treatments Using SGRT
Accuracy of Treatments -- Tangents
For tangents:
Tattoo: 1.73 ± 1.33 cm
Tattooless: 1.29 ± 0.79 cm
Significant improvement
in vertical reproducibility
(breath hold)
For patients with tattoos,
less accurate in lat/long
directions

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Tattooless DIBH Breast Treatments Using SGRT
Workflow -- Tangents

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Tattooless DIBH Breast Treatments Using SGRT:
Impact on Treatment Times -- 1-iso Regional Nodal Irradiation
3-minute reduction in daily setup time,
an average of 4-minute reduction in daily
treatment time. (p < 0.01)
Significant reduction in first day time,
~ 10 minutes. (p < 0.01)

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Tattooless DIBH Breast Treatments Using SGRT
Accuracy of Treatments -- 1-iso RNI plans
For 1-iso RNI plans:
Tattoo: 1.52 ± 0.71 cm
Tattooless: 0.63 ± 0.58 cm
Significant improvement
in vertical reproducibility
(breath hold) and lateral
positioning

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Tattooless DIBH Breast Treatments Using SGRT
Workflow -- 1-iso RNI plans

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Tattooless DIBH Breast Treatments Using SGRT:
Impact on Treatment Times -- 2-iso RNI
Still significant gains in daily setup and
treatment compared to 1-iso plan setup
with tattoos, with less variation in times
Average reduction of 5 minutes from v-
sim day and reduction of 3 minutes from
daily treatment times

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Tattooless DIBH Breast Treatments Using SGRT:
Impact on Treatment Times -- 2-iso RNI
the shifts between
plan isocenters results
in 3D average shift-
offsets on the order of
1.8 mm

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Tattooless DIBH Breast Treatments Using SGRT:
Workflow -- 2-iso RNI

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Tattooless DIBH Breast Treatments Using SGRT:
Discussion
There is no correlation between most patient demographics and set
up time and deviation, treatment time and # of images with 2
exceptions in the tattooed cohort:
1.For darker-skinned patients and complex plans, treatment times
are significantly longer when using tattoos to set up (~ 10
minutes).
The accuracy of the treatments was not impacted. In the tattooless
cohort there is no difference in setup times.

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Tattooless DIBH Breast Treatments Using SGRT:
Discussion
2. For tattooed patients, there is a correlation between
how experienced the RTT group was at using AlignRT
(ie, as strong as the newest user) and the number of
images taken per session.
There is no correlation in the tattooless cohort.
There is a brief increase in total treatment time with
the adoption of new technology, with a subsequent
decrease

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Tattooless DIBH Breast Treatments Using SGRT:
Summary

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Tattooless DIBH Breast Treatments Using SGRT:
Summary
Summary
•Patient satisfaction and autonomy is an important factor in quality care
•Important to set workflows and protocols staff feels comfortable with
•SGRT allows for verification of shifts
•Can reduce # of images/repeat images
•Can reduce treatment timeslots
•SGRT can allow for a tattoo-/mark-free workflow
•SGRT allows for more accurate initial setup
•SGRT allows for consistent setup times

29. Tattooless DIBH Breast Treatments Using SGRT:
Accuracy, Impact, Workflows
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Learning Objectives Met:
üSGRT for tattooless DIBH breast treatments is feasible
üSGRT with tattooless DIBH breast setups is accurate
üSGRT combined with tattooless treatments is faster than relying on tattoos
üSGRT for tattooless treatments can fit seamlessly into current DIBH workflows

30. Thank You!
Huge thanks to the superstar
radiation therapy team

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Accuracy and Time Savings of Tattooless DIBH Breast Setups:
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