SGRT Community Meeting 2021 - London Presentation by: Suzanne Coupland Advanced Imaging Lead Radiographer Raigmore Hospital, Inverness

1. FROM DIBH, TO EVERY
FRACTION, EVERY PATIENT
Suzanne Coupland
Advanced Imaging Lead Radiographer
Raigmore Hospital, Inverness

2. RADIOTHERAPY AT RAIGMORE
1 Siemens Somatom CT Scanner
2 Varian Truebeam Linacs
3 AlignRT systems
SimRT from VisionRT

3. SITES WITH SGRT
Breast – All sites, including VMAT, DIBH, partial,
nodes, boosts inc electron, bolus - Tattooless
Thorax – All sites - Tattooless
Pelvis – All sites – Tattooless
Non standard set ups, inc H+N without BDS, limbs

4. WHY SGRT?
 Align RT system first purchased 2009/10….
....we never used it!
 Bought to improve accuracy but….
….interface with old Elekta linac made functionality too
limited
 Then DIBH became the focus….
- we already had an automatic system
- did not need to manually control gating
- we only needed to purchase the interface

5. IMPLEMENTATION
Upgraded existing SGRT interface to support DIBH in September 2017
Had 1 system, but 2 linacs….
 Same core trainer (Radiographer)
 Small department – 18 radiographers
 Small patient numbers – approx 700 per year
 Agreed to use for all breast patients
 Staff confidence slow to build
 MV ‘during’ images taken, every patient, every fraction
 Had to wait for 2nd system to be installed – upgrade TB

6. IMPLEMENTATION
Initially….
 Set to tattoo, then use SGRT – shifts reversed – frustrating,
time consuming, more manual handling
 Hard to interpret the data – unfamiliar
After time....
• Staff confidence built
• Strong teamwork developed
• Imaging confirmed patient positioning was correct
Installed on 2nd Linac April 2019:
All staff fully trained to same standard, enabling smooth
transition & service development

7. SGRT BREAST
Quickly established removal of iso tattoo
Ignored lat tattoos - less manhandling
Pt positioning became quicker
Trialled for many months and audit undertaken
Audit proved SGRT was at least as good as tattoos
7th Oct 2019….
First tattooless breast patient treated….
….C/W + SCF + Axilla, DIBH & bolus!

8. BREAST WORKFLOW
•Check ROI
•Position patient
•Check alignment*
•Adjust patient
•Autoset to iso position
•‘Monitor’
•Adjust patient & couch
•Repeat

9. SGRT THORAX
November 2019: Confidence high, but...
 Imaging demonstrated variable shoulder positioning
 Early attempts with SGRT did not improve shoulders
 STOP - address immobilisation
 Interim decision to use wingboard + thin mattress
 CBCTs confirmed shoulder positioning improved
 SGRT used with tattoos to gain experience and confidence
 New immobilisation equipment acquired
 Audit undertaken
 No significant difference between tattoos v SGRT
15th March 2021….First tattooless thorax patient treated

10. VMAT plan delivered in 7 mini arcs to avoid spine and arms

11. CBCT v CT

12. SGRT PELVIS
Started using SGRT April 2021, after upgrade &
installation of Postural Video
Experienced enough to know tattoos are
limited!!
Few hiccups with ROIs
Observed pitch issues corrected if patient
moved self sup / inf
Positioning became quicker
Less manhandling was required

13. ROI Adjusted according to patient
Can be amended as many times as required to
provide the most accurate information, quickly and
easily

14. PELVIS SET UP

15. WHAT ABOUT EVERYTHING ELSE…?

16. WE HAVE A SOLUTION FOR THAT!

17. Non Standard H+N
Metastatic neck mass
20Gy in 5#

18. SGRT
Demonstrates
set up within
2mm

19. Treatment staff concerned set up a little “too simple”
SGRT Limb

20. CBCT v CT
Accuracy within 2mm

21. THIGH SARCOMA

22. LEG ROI

23. #1 #2 #4 #5

24. METASTATIC NODAL DISEASE
5-point
DSPS Shell from
Macromedics
55Gy in 20#

25. 5-Point
DSPS

26. 5-POINT
DSPS

27. 5-POINT DSPS
 Inconsistency in shoulder positioning
 No control
 No visibility
 No adjustment
 Fixing something mobile to something rigid
 Compromised image match – regardless of imaging
modality!

28. 2. CUT OFF SHOULDERS – 3 POINT DSPS – USE SGRT
• No consultant / planning / physics time required
• Radiographer-led process
• May not work – RESULT IN DELAYED REPLAN, time lost
1. REPLAN
• VERY limited consultant / planning / physics time
• Remake the mask, rescan, replan, repeat
• No guarantee of improved reproducibility – same
process

29. 3-Point
DSPS

31. BUT....#12
Position too inferior

32. WHAT DID WE LEARN?
DSPS position vital for neck extension
Shoulder ROI adjusted multiple times
Shoulder positioning worse the more we tried to
correct ? Patient specific
Needed a Treatment ROI when Gating
We were able to improve positioning accuracy
with SGRT over 5-point DSPS
 Reduced exposure – no extra CT, no replan
 No additional consultant / physics input

33. WHERE ARE WE NOW?
‘Gated Capture’ for Lung SABR
 Monitor patients during treatment delivery
 May indicate if additional CBCT is required
Shoulder less masks
 Inconsistency with shoulder positioning
 Increased accuracy
Open faced / faceless masks
 More control
 Increased accuracy
Thorax – Arms by Sides
Palliative sites

34. FACELESS MASK
 Test on patients for Whole Brain XRT
 Limited progress due to CT Sim software
 Develop to other H+N sites, including shoulderless??
 2 Dahanca H+N patients treated so far with mixed
results....
.....extremely anxious patient – only way to treat but 5-
point shell and custom headrest

35. PATIENT FEEDBACK
“Tattoos are
permanent so why
tattoo people if it
could be done
another way?”
“To have the option - I
don't think there's many
women who would
choose a tattoo”
“Tattoos should be
your choice, not
because of a
medical procedure”
“If I needed to have
tattoos to have the
treatment, then that’s
ok, it doesn’t bother
me”
“I don’t need
tattoos? That’s
fantastic!!”

36. STAFF FEEDBACK
It solves
positioning
issues without
imaging
Not pulling skin
around achieving
little
More detailed set up
information for accurate
set up
Removes the stress of
manual gating
Reduces our manual
handling risks-taking it
away almost completely!
As a short and currently
pregnant rad this is great!
More efficient
workflow for DIBH
Obvious benefit of
treatment accuracy being
able to continuously
monitor patient motion

37. BENEFITS OF SGRT
 User friendly
 Non invasive
 Tattooless
 Quick
 6 Degrees of data
 Comparison with CT outline
 Small tolerances
 Automatic Gating
 Improved accuracy
 Reduced repeat imaging
 Suitable for all sites
Patient Comfort does not compromise accuracy

38. WHAT DO YOU NEED?
SGRT System/s
Engaged core staff group – Physics and
Radiographers
Vision
Contingency plan for tattooless

39. ANY QUESTIONS?
suzanne.coupland@nhs.scot