Clinical implementation of tattooless treatment for breast cancer patients using SGRT

Kimm Fremeijer
RTT
Erasmus MC Rotterdam
Netherlands

1. CLINICAL IMPLEMENTATION
OF TATTOOLESS TREATMENT
FOR BREAST CANCER PATIENTS
USING SGRT
Kimm Fremeijer
Sr. RTT @ Erasmus MC
[email protected]

2. Overviewdepartment
LocationsRotterdam andDordrecht, theNetherlands
6 Elekta Versa HD , 4 Ethos, 2 Cyberknifes,
Hyperthermia, Brachytherapy
6 AlignRT systems on ElektaVersa HD
4 Identify systems on Ethos
Annually~1000 breastcancerpatients
Leftsidedand< 70 yrs→DIBH

3. SGRT Timeline EMC
2017 First AlignRT systems installedin Dordrecht
2018 ClinicalimplementationAlignRT forDIBH
breastpatients
2021 Setup allbreastpatientswithuseof AlignRT
2021 Clinicalimplementationof Real Time Coaching
device fromAlignRT forDIBH breastpatients
2022 Clinicalimplementationof VMAT-gatedDIBH
forbreastpatientsusingAlignRT
2023 Tattoolesstreatment forallbreastpatients
@ locationDordrecht usingAlignRT / Identify
AlignRT (VisionRT)
Identify (Varian)

4. ClinicalimplementationSGRT for
leftsidesDIBH breastpatients
StudyOnline Treatment Monitor (Theraview NT) vsAlignRT (VisionRT)
•2D versus 3D

5. Monitoring duringbeamon open fields vs. Monitoring entiretreatment

6. Goodagreement betweenbothsystems, meandeviation< 1 mm (±1 mm)
Penninkhof et al, TIPSRO 2022; 21: 51-57.doi: 10.1016/j.tipsro.2022.02.001

7. Setup breastpatients
usingbothtattoos andSGRT
•Tattoos placedon solidreferencepoints
•Necessarybecausenotalllinacshave SGRT
•Move couch tofront andleftsidedtattoo
•Check position of thepatienton breastboard
•UseCouch Move Assist (CMA) togo toisocentre
•Position patientwithuseof AlignRTandPosturalVideo
•CBCT online procedure
•Monitor patientduringtreatment usingAlignRT
•Manual interruptifpatientmoves outsidetolerance

8. Results
Time to complete the imaging procedure for patients’
setup based on tattoos versus setup using the SGRT
system.
•168.7 ±44.0 s without SGRT-setup
•152.8 ±33.2 s with SGRT-setup.
Comparison of the online corrections (rotations and
translations) between treatments with and without
SGRT-setup revealed small differences, not
considered clinically significant
LessCBCTswereneededforadequate positioning,
especiallytheposition of arm andchin.

9. Clinicalimplementationof Real Time
Coaching device forDIBH breastpatients
•A visual feedback system for the patient improves patient compliance to DIBH
•Breathhold duringCBCT similaras duringtheplanning CT
•Lessrotations→lesscomprimisingduringCBCT match
•Duringtreatment:
•Smaller deviationsin VRT-andLNG-directionandin amplitude
•Betterreproducibilitybetweenallbreathholdswithinonefraction
•Improvementin stabilityof thebreathhold

10. Clinicalimplementationof VMAT-gated
DIBH forbreastpatientsusingAlignRT
As presentedlast yearbySophie Huijskens:
“SGRT-based automated VMAT gating for left-sided breast DIBH treatment proved
highly efficient with a median 51sec beam-on time per BH, resulting in a median of
4 BHs per fraction, while staying easily within gating window tolerances.”
-33 patientswereincludedwithdifferenceof > 1 cm in SSD betweenFB andBH
CT-scans
-median intra-DIBH and intrafractionalDIBH reproducibility were ~1.0mm in each
direction

11. •Duringthestudythepatients
couldchooseiftheywanted
audio coaching fromanRTT or
do itthemselves.
•The first fractionwas always
withaudio coaching
•36% chose todo itthemselves

12. Identify on theEthos
Different camera angles
Setup on referencepoints insteadof isocentre
Slightlydifferent ROI’sbecauseof bore
No video function

13. Tattoolesstreatment forallbreast
patients@ locationDordrecht
2018: 2 linacswithAlignRT & 2 linacswithout SGRT = tattoos necessary
2023: 4 linacswithAlignRT/Identify & 0 linacswithout SGRT = tattoos no longernecessary
✓Experiencewithpatientsetup usingSGRT
✓Experiencewithpatientmonitoring usingSGRT
✓CBCT online procedure
❑Risk analysis
❑A protocol on how to handle in case of technical failure of the SGRT system
❑Fixed reference points, suitable for all breast/thoracic wall patients for setup
❑A short presentation for the RTT’s

14. Risk analysis
•No new system
•Similar patientpositioning as before
•CBCT Online procedure
•Alllinacsequipped withSGRT

15. A protocol on how to handle in case of
technical failure of the SGRT system
•Alignpatienton thefixedreferencepoints
•Move couch toisocentre
•CBCT online procedure
•Usematch criteria tojudgeifpatientpositioning is withintolerance
•Ifnot→re-alignpatient→new CBCT
•Maximum of 3 CBCT’sper fraction

16. Fixed reference points, suitable for all
breast/thoracic wall patients for setup
Length nippleaffectedbreast= positionon thebreastboard
Width middleof thesternum
Height dorsalside of theaffectedbreast
Exceptions:
•No nipple?→lengthof thenippleof theoppositebreast
•No breast?→heighton thedorsalside of theoppositebreast
•No breasts? →heightin themiddleof thetorso
lengthon thescarof theaffectedside
Example: right breast

17. Sofar
More than140 breastpatientsscannedwithout tattoos fortreatment
More than80 patientsfinishedtheirtattoolesstreatment.
The RTT’s are very positive; they now have a uniform workflow for positioning all
breast/thoracic wall cancer patients.
In addition, the entire CT procedure is finished in a shorter time.
The patients react positively surprised; they no longer will experience the cosmetic
and psychological impact of tattoos. Analysis of the accuracy of patient setup is
ongoing.

18. Future
Based on the positive results, a similar procedure will be implemented at the linacs
in our main location in Rotterdam early 2024.
In addition extension of tattooless treatments to other treatment sites will start.
Bytheend of 2024 ourwholedepartmentwillbetattooless

19. Maarten Dirkx
Joan Penninkhof
Kirsten Offereins
Cynthia van Wanrooij
Sophie Huijskens
Britt Kunnen
Sandra Quint
Allmycolleaguesandpatients@ locationDordrecht
Thanksforyourattention!