MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO

MOTION MANAGEMANT IN LUNG SBRT BY DR KANHU CHARAN PATRO

1. Motion management in L ung cancer 5/3/2024 1 Dr Kanhu Charan Patro MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC Clinical Director, HOD (Radiation Oncology) ISRo - I nstitute of S tereotactic R adiation o ncology Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam [email protected] /M- [phone]/ www.drkanhupatro.com

2. What is SBRT- THE TRIO? Ultrahigh dose radiotherapy Strict immobilization Motion management 5/3/2024 2

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4. Organs effected by respiration Lung Mediastinum Heart Breast Pancreas Liver Kidney Biliary 5/3/2024 5

5. Motion direction Superior inferior Mediolateral Anteroposterior 5/3/2024 6

6. Is lung moves? 5/3/2024 7 Yes As you go from apex to Lower movement increases As you go from medial to lateral movement increases

7. MANAGEMENT OF DIFFUSE GLIOMAS 5/3/2024 8 Errors

8. Steps MOTION MX

9. SBRT WORKFLOW Simulation Planning TX Delivery M o ti on Veri f ication L ocali z ation Motion Management Delivery

10. MANAGEMENT OF DIFFUSE GLIOMAS 5/3/2024 13 SBRT – Immobilization

11. ORGANS DO NOT FOLLOW STATUE GAME

12. Everybody is a king when everything is inside the ring [PTV]

13. Motion Management 5/3/2024 16

14. RADIATION ONCOLOGIST-THE ARJUN

15. Free breathing VS Motion managed 5/3/2024 18

16. Is motion being straight forward? No Hysterical motion 5/3/2024 19

17. GROSSLY ITV generation Abdominal compression Breath holding Gating Tracking 5/3/2024 20

18. What are available menu ? ELEKTA – ABC - BREATHHOLD VARIAN - RPM CYBERKNIFE – SYNCHRONY CYBERKNIFE- FUDICAIL OTHER COMPRESSION- ABDOMINAL COMPRESSION ITV GENERATION VOLUNTARY BREATH HOLD 5/3/2024 22

19. 5/3/2024 23 ITV GENERATION

20. ITV GENERATION Fluoroscopy mode 4D CT SLOW CT MULTIPHASE CT

21. 4D CT 4D CT  uses a new technology that captures the location and movement of your tumor and the movement of your body's organs over time . This is valuable for accurately treating tumors located on or near organs that move, such as those in the chest and abdomen . 4D CT describes various techniques for obtaining CT data correlated with patient respiratory phase information so that the changes associated with respiration (or other motion) are displayed . Phasing the respirtory cycle

22. Elekta symmetry Rspiratory phase acquisition

23. MULTI PHASE SCAN 5/3/2024 31 INSPIRATION EXPIRATION FREE BREATH

24. Artefact in motion mx 5/3/2024 32

25. SLOW CT Computed tomography scan operated slowly and/or multiple slices taken are averaged, i.e. multiple phases of respiration are recorded by slice Generally available on most computed tomography scanners. Loss of resolution, which may lead to tumour blurring and subsequent increase in observer error in tumour and OAR delineation

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27. 5/3/2024 37 Abdominal compression

28. Abdominal compression

29. Breath holding 5/3/2024 40

30. HOLDING Assists breath-hold by use of a valved spirometer . Often at moderate or deep breath-hold. Can reduce motion artefacts . Improvements in dose to organs at risk. Potential for dose escalation compared with free-breathing technique Patient selection important; non-compliance of patients with poor respiratory function. Increase in quality assurance procedures

31. ELEKTA ABC Active breath coordinator Based on breath hold During breath hold treatment Works like spirometry Needs good lung function 5/3/2024 43

32. Nose and mouth peiece 5/3/2024 44

33. Green is the beam on 5/3/2024 45

34. Elekta ABC

35. VOLUNTARY BREATH HOLD USING WIRELESS DOOR BELL

36. GATING 5/3/2024 48

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38. 5/3/2024 50 Particular phase ITV

39. GATING Delivery of radiation within a specified part of the patient’s breathing cycle termed ‘the gate ’. Phase or amplitude based. Uses external respiration signal e.g . infrared, spirometry , thermistors or internal fiducials . internal fiducials . Imaging and treatment synchronised with patient’s breathing cycle

40. PHASE BASED TREATMENT- CHOOSING PART OF DUTY CYCLE 5/3/2024

41. Varian RPM gating synchronization

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43. PRESSURE SENSOR GATING

44. Camera based gating 5/3/2024 58

45. Vision RT- SGRT - GATE RT 5/3/2024 59

46. Tracking 5/3/2024 61

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52. Synchrony

53. IN SUMMARY

54. External signal – Gating Amplitude based Phase based Internal signal - Tracking Breath hold is also a type of amplitude based gating 5/3/2024 74

55. 5/3/2024 Various Motion management systems

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58. MOTION MANGEMENT VIDEO

59. WHICH MOTION MANAGEMENT SYSTEM IS BETTER?

60. GOSSIP- WHOSE SPOUSE IS BETTER?

61. ANSWER- WHAT MANAGEMENT ACQUIRES

62. Managing the Management

63. Stereotaxy class

64. Target delineation class

65. Radiology class

66. Neurooncology Class

67. SRS/SBRT

68. Scan through Google lens Go to free materials 5/3/2024 90

69. Kanhu 5/3/2024 91