A presentation by Phil Silgen, MS, DABR, Chief Medical Physicist, HealthEast Cancer Care, at the Vision RT dinner at AAPM 2017.

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Implementing SGRT for Left Breast DIBH
from Start to Finish
Phil Silgen, MS, DABR
Chief Medical Physicist
HealthEast Cancer Care
Surface Guided Radiation Therapy: Turning Plans into Reality
2017 AAPM Meeting VisionRT Dinner Event

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Disclosures
Surface Guided Radiation Therapy: Turning Plans into Reality
2017 AAPM Meeting VisionRT Dinner Event

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Outline
1. Practical Considerations for Starting a DIBH Program
2. VisionRT System Implementation with Varian TrueBeam 2.0/2.5
3. Evaluation and Simulation
4. Treatment Planning Considerations
5. Patient Setup and Treatment

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1. Practical Considerations for Starting a DIBH Program
1. Technology
2. Literature
 “A Voluntary Breath-Hold Treatment Technique for the
Left Breast With Unfavorable Cardiac Anatomy Using
Surface Imaging. Gierga, et al. IJROBP 2012
 “Clinical experience with 3-dimensional surface matching-
based deep inspiration breath hold for left-sided breast
cancer radiation therapy” Tang, et al. PRO (4) 2014.
3. Training
4. Staff “Buy-In” / Teamwork
5. Consistency
 Patient Experience

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2. VisionRT System Implementation with TrueBeam 2.0/2.5

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3. Evaluation and Simulation
Patient Positioning:
Minimize Complexity / Maximize Reproducibility
• Wing-Board vs. Slant-Board
• VacLoc Only
 Minimize Apparatus
• Hand / Arm Position
 Patient to Grasp Bar

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3. Evaluation and Simulation
Discussion with the Patient:
• Explanation of the DIBH Technique
• Patient Comprehension of Process
• Evaluation:
 Is the Patient “Willing & Able” ?
 Can the Patient hold her breath (Approximately 20 sec) ?
 What if the Patient is not a Candidate?

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3. Evaluation and Simulation
DIBH - Deep Inspiration Breath Hold
• Comfortable Deep Breath
 Hold Breath about 20 sec
• Nasal vs. Mouth (Chest vs. Belly Breathing)
• No Arching Back
• Reproducible Breath

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3. Evaluation and Simulation
CT Simulation Workflow:
• Evaluation of Consistency of DIBH
 “When you are ready, Exhale then take a deep breath in and hold it”
 “Poor-Man’s” Simulation – BB
• Free-Breath (FB) CT Acquisition / DIBH CT Acquisition
• CT Evaluation
 Heart Position w/ DIBH vs FB

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4. Treatment Planning Considerations
• Automatic Fusion of CT’s upon Import to Eclipse

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4. Treatment Planning Considerations
• Plan on DIBH Scan
“Keep it Simple”
• FiF Tangents
 Limit 3-5 Segments
• Avoid IMRT
• Avoid Mixed Energies

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5. Patient Setup and Treatment
AlignRT Software
• Import DICOM
• 1 Plan, 2 Structure Sets
 FB Body – Setup
 DIBH Body - Treatment
• Define Monitoring ROI’s

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5. Patient Setup and Treatment
1. Setup to General ISO – Use LASERS to Position Mid Left Breast
2. Use FB Reference Image for Initial Alignment
 Manually Adjust Rotations and Translations
3. Turn ON DIBH Reference Image
 ”When you are ready, Exhale then take a deep breath in and hold it”
 Minor Adjustments to Patient Position
 DO NOT ADJUST Vert!

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5. Patient Setup and Treatment
Acquisition of Portal Images
• Verify CW & Breast Surface Tissue
(Flash)
• Thresholds for Acceptability
 Less than 3mm in any Direction – Do
Not Shift
 ≥5mm – Shift Patient and Re-Acquire
AlignRT Reference Image
 Physician Judgement Call

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Conclusions
• Implementation of SGRT for Left Breast
DIBH Treatments has been
Straightforward
 Referenced Workflow Cited is Scale-able
to any clinical environment
• Varian TrueBeam and VisionRT
Technology Partnership
• DIBH Treatments with AlignRT Software
have been Efficient
 No Additional Time Necessary
(15 min Time-Slot Works)

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Thank You!