The document discusses considerations for implementing a clinical surface guided radiation therapy (SGRT) program. It covers objectives like system setup, defining the program's scope, and implementation strategies. The speaker outlines their commissioning process and quality assurance testing. Their SGRT system achieves sub-millimeter accuracy. A phased implementation approach is suggested, starting with complex treatments and expanding over time. Continuous evaluation of new sites and adjustment of tolerances is important for ongoing program development.

1. Michael J Tallhamer M.Sc.
DABR
Chief of Radiation Physics – Centura Health
mike.tallhamer@gmail.com
Every Patient, Every Treatment: Expanding SGRT for All Indications
Considerations for the ongoing implementation of a clinical SGRT program

2. Disclosures
- The opinions expressed in this talk are solely mine and not those of my
employer.
- The descriptions of workflows and the equipment used during this talk are not
intended as an endorsement of any products or services
- I have provided educational and technical consultation services
- Private Institutions
- Academic Universities
- Vendors as it pertains to this talk (Varian and Vision RT)

3. Learning Objectives
02
01
03
04
SGRT Implementation
Quick Tour of our program
System Setup
Having a good foundation
Defining Your Program
What do we intend to treat and what if it
changes?
Implementation
How to make it work in my center

4. Experience 01
Setup 02
Implement04
Define 03
Ready…Set…
These steps will hopefully give
you a general approach for any
system illustrated along the way
with items from our experience
GO!
Implementations may vary by site
and by system selected. It is an
iterative process to get to a well
defined set of guidelines for your
department
Survey of Topics

5. Virtual Site Visit
What does SGRT look like at my centers
This is your 10₵ tour

6. CT Simulation Process
CT Simulation accomplished with Philips Brilliance Big Bore
scanners using Vision RT’s GateCT product for 4DCT simulation,
Medrad Stellant Injectors for contrast studies and LAP Dorado
Lasers for placement of isocenter at the time of sim
Virtual simulation and placement of lasers controlled through
Varian Eclipse Virtual Simulation software. Integrated Varian
Aria/Eclipse environment also used for planning and delivery
Implementing Complimenting Technologies for SGRT and Motion Management

7. Delivery Process
Delivery is accomplished on Varian TrueBeam accelerators v2.5
MR1 with HDMLCs, IGRT orPerfect Pitch 6DoF Couch,
Advanced Imaging and MMI for direct integration with our SGRT
systems
Our chosen Surface Guided Radiation Therapy (SGRT) system
for delivery is AlignRT (Vision RT) or OSMS (Varian)
Implementing Complimenting Technologies for SGRT and Motion Management

8. Immobilization System
Implementing Complimenting Technologies for SGRT and Motion Management
Choose something that works well with your SGRT system
Orfit 3-point and 5-point open face masks
for Intracranial SRS, SRT of the H&N,
SBRT of upper lobe (apex) tumors of the
lung, neck (carotid body tumors), and C-
Spine, standard treatments of H&N, Brain
(Whole or Partial)…etc.
Orfit thoracic mask for SBRT/SRT of C and
T Spine, standard lung, esophagus,
stomach, hilum, mediastinum…etc
Orfit body / lower abdominal mask for
pelvis (GYN, Prostate, GI, Rectum,
Anus…etc), liver…etc. Also used for
uniform abdominal compression for SBRT
lung, liver and pancreas

9. Complex
Intermediate
Simple
What are we treating
Intracranial
SRS
(mets)
DIBH SBRT
Standard
Breast
Pelvis
Prostate
GI
DIBH Left
Breast
SBRT
Lung
SBRT
Liver
Palliative
Prone
Breast
Trigem
H&N
Partial
Brain
Brain
GYN
SBRT
Spine
SRT
H&N
Acoustic

10. Site Breakdown
4 Hospitals Currently Using SGRT and IGRT for daily delivery of Radiation Therapy
3DCRT, DIBH, IMRT, VMAT, SBRT, SRS
6 of 10
9 of 10
7 of 10
9 of 10

11. System Setup…The 5₵ Tour
Now you have the thing so what do you do with it?
Acceptance, Commissioning and Performance Measures
Determining how SGRT stacks up.

12. Understand You Tools
Delivery
Integrated delivery system
Beamline Imaging
Imaging verification
Before, During, and After
On Board Imaging
Imaging verification
Before, During, and After
Setup/Monitoring
with SGRT
SGRT adds a new dimension in patient setup, safety, and motion management

13. TG-76TG-121
TG-142TG-135
TG-104TG-179
06 01
02
0304
05Quality assurance of medical accelerators
The Role of In-Room kV X-Ray Imaging for
Patient setup and Target Localization
The Management of Respiratory Motion in
Radiation Oncology
Off-Label Use of Medical Products in Radiation Therapy
Quality Assurance for image-guided radiation therapy
utilizing CT-based technologies (not yet published)
Quality Assurance for Robotic Radiosurgery
Task Group 147
Quality assurance for nonradiographic radiotherapy
localization and positioning systems
* Also references principles of TG-100, TG-40 (even though it also references TG-142) and TG-154 on US Guidance

14. Commissioning
Acceptance
Performance
Evaluation
This includes measuring the system accuracy, determining
system limitations, and developing operating procedures and QA
schedules.
Some of these tests will be completed as part of the acceptance
test with the vendor; however, in most cases, the acceptance
test is at the discretion of the vendor and may not satisfy all
clinical recommended quality assurance
It is important to keep in mind that
acceptance tests demonstrate only
that the equipment is working as per
the specification.
Validation of software and analysis tools
under as many clinically relevant conditions
as possible (not directly listed in TG-147)
Task Group 147
Quality assurance for nonradiographic radiotherapy
localization and positioning systems

15. Monthly
Daily
Annual
Monthly QA by or under the supervision of a QMP
should include all tests performed daily with the addition of
the following.
• Gating
• Static Localization (Hidden Target)
• Dynamic Localization
• Documentation
• Vendor Recommended
A QMP should perform the following daily
QA tests or delegate them to another
member of the radiation therapy team,
like a radiation therapist. If the tests are
delegated, a QMP needs to review the
test results in regular intervals.
• Safety
• Static Localization
• Documentation
• Vendor Recommended
In addition to the tests performed daily and
monthly, the following tests should be
performed annually by or under the
supervision of a QMP.
• System Stability
• System Integrity
• Extended System Performance
• Positioning Accuracy
• Extended Gating
• Data Transfer
• Documentation
• Vendor Recommended
Task Group 147
Quality assurance for nonradiographic radiotherapy
localization and positioning systems

16. System Accuracy
End-to-End Hidden Target Accuracy by Technology
With the exception of the CyberKnife all systems are add-on style systems (i.e. third party) and subject to the underlying accuracy of
the linac itself.
Vision RT
0.2mm BrainLab
0.4mm
Frames
0.2mm
CyberKnife
0.2mm
Varian OGP
1.2mm
The combined patient setup accuracy should conform to the recommendations of TG142 of 1 mm for SRS and
SBRT and within 2 mm for conventional treatments as stated in TG-147.

17. So…What do you want to treat with SGRT?

18. What do you want to treat with SGRT?
What are your doctors saying?
“DIBH Breast, SBRT,
and SRS”
“I just want my setups
to be better and my
images to look good”
“Everything!!”

19. When looking for what others are doing
Other resources
X
SGRT.org
Mission: To facilitate a
radiation oncology peer
to peer environment of
clinical professionals
working together to
adopt and promote best
practice of SGRT
across all applicable
indications to ensure
quality patient care.
MedPhys Lists
Seeing more and more
from individuals who
have these systems
posting questions and
getting good feedback
01 02

20. 01
02
Commissioning
This includes measuring the system accuracy, determining
system limitations, and developing operating procedures and
QA schedules.
Performance Validation
This should include assessing the performance of the system under various
clinically relevant conditions and is an ongoing process
Examples (Deformable Surfaces, DIBH for SBRT, SRS in BOS and High
Neck…etc)
Commissioning vs Performance Validation
What if what I want to do changes over time (it will)

21. Implementation Strategy
I’m happy with how this thing is working, I know what I want to treat.
Now lets take it to the machine and break it!

22. Complex
Intermediate
Simple
What you “saw” treated with SGRT
Intracranial
SRS
(mets)
DIBH SBRT
Standard
Breast
Pelvis
Prostate
GI
DIBH Left
Breast
SBRT
Lung
SBRT
Liver
Palliative
Prone
Breast
Trigem
H&N
Partial
Brain
Brain
GYN
SBRT
Spine
SRT
H&N
Acoustic

23. What you didn’t see
A progressive implementation of your chosen
SGRT technology helps in the adoption
process
+80%
ComplexSRS/SBRT, DIBH SRT…etc.
+50%
Intermediate
DIBH, Prone Breast, Lung
Prostate
20% Simple
Rt Breast, Brain, Pelvis
Post
Initial Training
(Initial process and
tolerances)
Post
On-site Training
(Refined process and
tolerances, incident learning)
Post Departmental Training
(Finalized process and tolerances, incident learning)

24. Don’t miss the forest for the trees
What do I do if there are problems?
People
Should be people using
the system
Place
Set a place to meet
(No phoning it in at
least at first)
Meet
Start weekly then move
to monthly and finally
quarterly
There will be problems
Have departmental champions from each
discipline (admin, physician, physics and therapy)

25. Onward and Upward
Identify a new application or
treatment site
Work out a process map to identify
areas of concern
Push phantom patient through new process
with entire team
After implementation, review patients for signs
that adjustments are needed
Each new treatment site you add to
your SGRT program should be
reviewed and evaluated
Implement

26. Tolerance Evolution
QA and Phantoms
• Your commissioning will help you develop a starting point for
tolerances for various applications of SGRT in your clinic
System Setup
• A base set of statistically reviewed tolerance levels can be set
as defaults (if your SGRT software allows) so that you can use
best practices to drive quality.
Using the SGRT systems output to drive quality

27. Tolerance Evolution
Patient Specific Phantom QA
• Running the system under ideal conditions can give you an
indication system performance
• This can help you determine expected clinical action levels
Real life application
• The tolerances should be evaluated over time.
• Tolerances should be adjusted to give you and your team
useful information (i.e. not too many false positives)
Using the SGRT systems output to drive quality

28. Tolerance Evolution
Using the SGRT systems output to drive quality
Feature based registration of the two traces suggests we can develop better action levels based on patient / plan
specific tolerances obtained during the standard QA measurement procedure.

29. Sounds Easy Right
What have we learned
X
What I Do
You’ve seen a short
glimpse of how I run
my program with the
equipment that I
currently have at my
sites
Setup
We have quickly
reviewed the current
guidance documents
from the AAPM on
how to validate these
systems
Define
We have discussed
the importance of
defining your goals for
how to get to your
Every Patient, Every
Treatment type of
program
Implement
We have cover a
quick overview of both
a simple rollout
strategy and an
ongoing
implementation
strategy for pushing
your program forward
using SGRT
01 02 03 04

30. Thank You Questions?
Michael J Tallhamer M.Sc.
DABR
Chief of Radiation Physics – Centura Health
mike.tallhamer@gmail.com
Every Patient, Every Treatment: Expanding SGRT for All Indications
Considerations for the ongoing implementation of a clinical SGRT program