Increased Efficiency through SGRT Usage for Prostate Treatments on a Bore-based System

Michelle Physic, RT(T)
Director of Radiation Therapy, Dana-Farber Cancer Institute / Brigham Cancer Center
SGRT US 2024

2. Increased
Efficiency through
SGRT Usage for
Prostate
Treatments on a
Bore-based System
2024 SGRT CONFERENCE
ARIZONA
MICHELLE PHYSIC

3. Agenda
About our Department
Hospitals
Sims/Linacs
Ethos install
Why Prostate
Genitourinary growth (GU)
AlignRT Equipment
Cameras
Inbore Ring System
Real Time Coach
Workflows
Sim
Backup setup workflow
Plan Preparation
Setup/Treatment – Prostate
Setup/Treatment - LIBH
Capturing SGRT surfaces

4. Our department
Boston, MADFCI
DFCI
BWH

5. Treatment Machine & SIMS
Truebeam
Blue
Truebeam
Yellow
Ethos
Silver
TX
Red
Sim 1
Siemens
Sim 2
GE
MR Sim
Siemens 3T
MR Linac
Viewray 0.35T
HDR/BRACHY
GECobalt 60
BEST
iX
Purple
Truebeam
Pink
Truebeam
Green
BWH
DFCI

6. Tattoo and
Mark Free
Award
Primary Disease Sites:
•Breast
•Lung
•H&N
•Some Prostate/Bladder/Palliative

7. Ethos – “Silver”
Go Live DateMarch 15, 2022
Photon MV energyHypersight, 6FFF
CouchVarian - Weight limit 502 lbs.
Main Disease Sites•Prostate
•Bladder
•Prostate SBRT
•Low Inspiration Breath Hold
Hours•5:30 am warmups
•6:30 am first patient
Patient Volume•40-60 patients
Time Slots •10 min – IMRT/VMAT
•40 min – Adaptive (5 slots)

8. Total Treatment Appointments
BenignBrachyBreastCNSGIGUGynH&NHemeMultiPedsSarcomaSkinThoracic
FY191111271073455299090671132581513696146617497832
FY2029912703461291083791029961431702986172171068
FY2161216483689354697819043114574771335176117915
FY2261267834244357793209925913295841028191151350
FY23612531244799297712343100711612937507241609151036
FY241383212824792094906677592765513644141510707
0
2000
4000
6000
8000
10000
12000
14000
FY19
- FY24
Site
FY19-FY24
FY19
FY20
FY21
FY22
FY23
FY24

9. Genitourinary: Total Treatment Appointments
90678379
97819320
12343
9066
FY19FY20FY21FY22FY23FY24
FY19FY20FY21FY22FY23FY24
Placing all GU patients on the ETHOS machine allowed to be tattoo-less

10. Equipment:
3 Camera Pods –
Outside Bore

11. Inbore Camera
a.Patient Imaging Assembly
b.Inbore Camera Mount
c.Locking Mechanism
Ring is detachable.
If moved, calibration is needed.

12. Inbore Camera
a)Camera
b)Speckle Projector
c)Illuminator and Speckle Projector

13. Real Time Coach

14. AlignRT Daily QA
Daily Plate QARaised Plate Calibration
Plate sits on top of risers

15. Simulation
•Patient is scanned
With 3 bb’s (RT, LT, Center) placed at arbitrary
point in pelvic area
•Setup Equipment:
- Pillows under head
- Combi Fix board
- Hands on chest
Marking Origin (MO)

16. Backup Workflow
•Marked patient templates are delivered to treatment machine
•Templates are also scanned into ARIA > Documents
On Treatment Machine:
•Couch vertical is recorded by therapists on Day 1 and noted in ARIA > Journal
•Isocenter is confirmed with imaging
Spirit level used to record
rotation
Template is created to mark
MO, any previous tattoos,
anatomical markings/blemishes

17. PlanningPLANNING
Outside of bore
The bb’s are the
coordinates used for
patient setup.
Inside bore
Patient is loaded to
treatment plan isocenter

18. Import DICOM for Patient Preparation
PLANNINGIMPORT into AlignRT

19. Selecting a Region of Interest (ROI)
§Recommended ROI’s•Extend ROI laterally to midcoronal
plane of patient
•Include patient skin surface only
•Do not include sheets or
immobilization
•Do not include abdomen or other
anatomy that is unstable
•May need to include more
anatomy superiorly on the laterals
when topography is limited due to
abdomen/heavy breathing

20. Evolution of ROI
This was the ROI we initially started with.Therapists find this more helpful
•Remove ROI across anterior pelvis altogether
•Don’t have to worry about center towel
accidently getting in the way of the ROI

21. Pelvic ROI
AP RT LAT
•Ensure the ROI wraps around the iliac crest anteriorly as much as possible
•Drawing an ROI too inferior on leg may introduce unwanted pitch issues

22. Setting Up the Patient
TREATMENT WORKFLOW

23. Setting up the Patient: Outside Bore
§Mode up patient on Ethos
treatment console
§Select load button on Ethos to
set initial couch coordinates
§Open patient in AlignRT
§Select CT SIM Body and begin monitoring
§Select Setup
§Level patient and zero out real time deltas

24. Postural Video
Inbore:
There is no postural video inside the bore.
Must remember to click on surface
Outside of BoreInbore

25. Setting up the Patient
§Load patient into bore
LOAD

26. Treatment Workflow: Inside Bore
§Switch to Treatment view
§Image patient
§Apply shifts
§Capture This Session Only reference
*This will ensure that patient is monitored for any
movement during treatment

27. Benefits of Inbore Monitoring
§Ensuring that the patient has not moved during
treatment.
§Reduces the need for repeat imaging/shifting
§As therapists we have been trained to monitor the
patient for any movement. Unfortunately, our
human eye can only capture gross movements (i.e.,
patient lifts arm, sneezes, coughs, etc.)
§Monitoring translational & rotational deltas
informs user if patient is out of tolerance (mm or degrees)

28. Benefits of Inbore Monitoring
•Some views of patient within the bore may be limited, due to patient
immobilization, etc.
•Again, deltas give real time information on patient position.

29. §In contrast to DIBH (Deep Inspiration Breath Hold), a technique used for breast treatment where dose is reduced to the heart and lungs.
§The main goal of LIBH is to stop internal organ motion to improve image quality thereby improving contouring. Patients were selected based on targets that were immobile.
§AlignRT has been essential to this technique workflow to capture a breath hold during treatment delivery.
§Patients are asked to take a small breath or comfortable inspiration.
§Breath size is unique to each adaptive treatment session)
§5 Cases treated thus far:
§LIBH Adaptive SBRT Retroperitoneum or Abdominal Node
§800cGy x 5 fx – 4000 cGy
Low Inspiration
Breath Hold
(LIBH)

30. LIBH Setup & Treament
1.Set up patient outside of bore with AlignRT
2.Load patient into bore to isocenter
3. Ask patient to breathe in and hold
4. Capture SGRT (this session only)
5. Note size of breath and document in ARIA (Journal)
6. Perform CBCT
7. Ask patient to breathe out
*Real Time Coach is
used to assist
patient with correct
breath hold

31. LIBH Setup & Treament
8.RTT begins contouring
9.Physics creates plan
10.MD approves
LIBH Adaptive SBRT Abdominal Node

32. LIBH Setup & Treament
11.Ask patient to breath in/hold
12.CBCT
13.If no shifts, proceed with
treatment in breath hold.

33. Capturing SGRT surfaces
Outside BoreInside Bore
Both This and Future Sessions &
This Session Only reference capture
options are available in Setup view.
This Session Only is available in
Treatment view, while This and
Future Sessions is unavailable.

34. What if I want to capture shifts?
Outside of BoreInside of Bore
RThis and Future Sessions
RThis Session Only
Q This and Future Sessions
RThis Session Only

35. What if I want to capture shifts?
Post Treatment
1 RTT (Driver)
1.Instruct patient to hold still.
2.Do not clear the last treatment field once treatment is complete.
3. The Couch Move buttons will light up in blue on the console.
4. Move couch slightly out of bore
5. Release buttons and re-select CBCT field on Ethos console
2 RTT
6.Enters room and selects load button on machine.
This will move couch out of bore to iso setup position
andincorporate the shifts from the CBCT
1 RTT
7. Switch to the setup cameras on AlignRT and capture a
new SGRT surface, select “This and Future Sessions”

36. Thank you
QUESTIONS?