Dibh breast treatments with bolus and image guidance

1. DIBH Breast Treatments with
Bolus and Image Guidance
May 3rd & 4th 2018
Jae Lee, B.A., R.T.(T)
Memorial Sloan Kettering Cancer Center

2. Clinical Flow Chart (Weekly Film)
Patient
to
Tattoos
Non-bolusSetup to
AlignRT
(DICOM)
DIBH
Portal
Film
Film
OK?
Bolus
To MD
orTreat
See KV
Flow
Chart
Yes
No
Reference
Surface Image
@ DIBH

3. Clinical Flow Chart (Daily KV Film)
Patient
to
Tattoos
Non-bolusSetup to
AlignRT
(DICOM)
KV Film Film
OK?
Bolus
To MD
orTreat
Make
Shifts
Yes
No
Reference
Surface Image
@ DIBH
Reference
Surface Image
@ DIBH
Bolus

4. Setup Day
• ROI set properly
‒ Not too big and not too small
‒ Correct side
‒ Color setting
• Satisfy AlignRT on breath hold
‒ Lights on
‒ Avoid path of AlignRT cameras
• Film
– Weekly, use only to verify
– No shifts necessary

5. ROI Selection

6. Treatment
•Satisfy AlignRT on breath hold
•Begin treatment
– Check couch vertical for consistency
– Learn patient’s length of breath hold
– Patient treated on breath hold
•If patient falls out of tolerance
– Ensure patient is correctly positioned (gantry at zero or out of
the view of the camera pods)
– Shift to satisfy AlignRT if necessary

7. Treatment With Bolus
•Satisfy AlignRT (DICOM image)
•Place bolus over treatment field
– Sticky Bolus is ideal
• Tape together if necessary
» Micropore > Durapore
•Make marks directly on pt to ensure position
•Create reference image on breath hold
•If patient falls out of tolerance
– Do not shift to satisfy reference image with bolus on
– Shift only to DICOM reference with bolus off
– Reapply bolus
– Create new reference image

8. Treatment With Daily KV Image
•Satisfy AlignRT
•Film
•Apply necessary shifts
•Create new reference image with KV arms
retracted
– Visually ensure patient has “same” breath hold when
capturing
•If patient falls out of tolerance
–Refilm and create new reference
– No manually shifts to reference image
• Treatment restriction (TrueBeam)

9. Treatment With Daily KV & Bolus
•Satisfy AlignRT
•Film
•Apply necessary shifts
•Create new reference image with KV arms
retracted (optional)
•Mark pt to ensure correct position
•Place bolus and capture reference

10. Moving Bolus Between Fields
• Capture a reference image with bolus for one
field and treat
• Between necessary fields, change bolus position
• Make sure pt is still in correct position
– Check DICOM image (non daily KV pt)
– Check marks made (daily KV pt)

11. Treating With Couch Angles
• Satisfy couch kicked angles using DICOM or
reference image from KVs
• Kicked couch out of tolerance
– Choose correct couch angle on dropdown
– Move gantry out of position and check
– Bring couch back to reference angle (zero) and check
• If pt is in tolerance
» Kick couch back to treatment position and create
new reference for that angle
• If pt is not in tolerance
» Satisfy AlignRT accordingly (weekly-dicom or KV-
reference)

12. AlignRT False Positives
• Shallow breathers
• Patient being setup to free breathing
– Can still satisfy DICOM
– Compromised treatment
– Lung and heart at risk

13. Shallow Breathing Patients
• Be in control of their breathing
• Visually monitor patient
• Check Magnitude Offset
• Hold beam manually if needed on TrueBeam
console
– Hold down the “Beam On” button
• Pauses beam while being pressed down
• Continues treatment immediately once released
– Efficient
• Ask physics to change tolerance (optional)

14. PAB, SCLAV & IMRT BREAST
TREATMENT
• Arm position may need adjustment even though
DICOM is completely satisfied
• Create a separate ROI region focusing only
around the clavicle portion of the shoulder
– Use as personal reference only
• Daily KVs (4 field)
– Do not rotate (yaw) more than 1 degree
– Avoid pitch and roll if you do not want to refilm
– TrueBeam “glitch”

15. Single Port Films Not Reliable
Orthogonal pair necessary for capturing reference image

16. “With Great Power
Comes Great
Responsibility”