This document discusses the Cleveland Clinic's experience using SGRT (Surface Guided Radiotherapy) for breast cancer treatments. It summarizes the Clinic's breast radiotherapy paradigms and how SGRT has been integrated into the workflow. SGRT is now being used for patient setup and monitoring in tangents and mono-isocentric breast plans. Initial data shows SGRT correlates well with portal imaging and has the potential to replace skin-to-skin distance measurements. Future directions include expanding the use of SGRT to more techniques and using it to allow for more reproducible setups and smaller margins.

1. SGRT and Breast Cancer
Radiotherapy: The Cleveland Clinic
Experience
Chirag Shah, MD
Associate Professor
Associate Staff
Director of Clinical Research
Taussig Cancer Institute
Cleveland Clinic Foundation

2. Disclosures
• Consultant- Impedimed Inc.
• Grant Funding- VisionRT

3. Introduction
• Radiation therapy is a
vital component of
breast cancer therapy
• Many different options
• Changing indications
• How to incorporate new
technologies into an
already complex field?

4. CCF Breast Radiotherapy Paradigm
• Breast conservation
– Standard Fractionation Whole Breast Irradiation
• Age < 40, LN+, Max hot spot > 107%
– Hypofractionated Whole Breast Irradiation
– Accelerated Partial Breast Irradiation
• 5 Days
• TRIUMPH-T- 2 day
– Intraoperative Radiation Therapy
• Age > 65, T1N0, ER+

5. CCF Breast Radiotherapy Paradigm
5

6. CCF Breast Radiotherapy Paradigm
• Postmastectomy Radiation Therapy
– Standard fractionation with RNI
• +/- Internal Mammary
• Considering hypofractionation
– Following Adjuvant Chemotherapy
• Primary Tumor- T3/4
• Nodal Status- Node positive/ECE
• Margins
– Following Neoadjuvant Chemotherapy
• Indications remain unclear (NCCN: use pre-chemo staging)
• Pathologic node positive
• Margins

7. CCF Breast Radiotherapy Paradigm

8. CCF Breast Radiotherapy Paradigm
• CT simulation
– Supine
• Prone for large breasted patients without RNI
– Breast Board
– Wire borders
– Wire scar
– Left breast cancers
• Scan with and without ABC
• ABC teaching/coaching

9. CCF Breast Radiotherapy Paradigm
• Treatment Planning
– 3D-CRT
• IMRT- re-treatment
– Techniques
• Tangents
– Field in Field
• Mono-Isocentric
• Dual isocenter
– Cardiac sparing
• Fuse ABC/Non-ABC scans- evaluate benefit
• ABC with cardiac block
• Alternatives- Prone, Cardiac block alone, IMRT, APBI
– Internal Mammary Nodes
• Partially wide tangents
• Electron match

10. Breast Volume
• More than 500 new cases seen each year at
CCF
• When changing techniques/paradigms:
– Quality and Safety
– Clinical Outcomes, Toxicity
– Efficiency, Use of Resources
– Patient challenges
• Distance
• Cost

11. Implementation
• Began utilizing VisionRT in Summer/Fall 2016
– One machine treating breast cancer patients primarily
– Initially added on to standard protocol
• Therapist learning period few weeks
– Patient set ups, drawing ROIs, importing, patient
positioning with yaw, pitch and roll
• No change in length of time slots for treatment
• In March, 2017 moved to new cancer center with
new linear accelerator
– Seamless transition with VisionRT, began using on day
1

12. To Date
• VisionRT is being used for tangents,
monoisocentric breast plans
• Not using with two isocenter and prone cases
– VisionRT capable of setup
– Plan to develop new workflow for these cases to
incorporate VisionRT
• Has worked on all cases except one
– Patient issue

13. VisionRT Set Up
• All cases
– Used for setup
– Patient monitoring
– During treatments- if patient moves, adjusted between fields rather than
during field
• Tangents
– Used to align patient
– Check medial tangent border for match and check SSD
• Mono-Isocentric
– Triangulate using tattoos
– Go to isocenter and use VRT for confirmation of alignment and to check SSD
• ABC
– Use VisionRT on inhalation breath hold
– Monitor during treatment

14. Initial Data
• Comparing VisionRT and portal imaging

15. Initial Data
• Replacing manual SSD with VisionRT

16. Conclusions
• VisionRT was integrated into CCF breast
radiotherapy paradigm
– No patient delays
– Same or enhanced throughput/workflow
• Therapists find it improves quality and safety,
patient assessment during treatment
• Data to date
– Correlates with portal imaging
– Potential ability to replace SSD moving forward

17. Future Directions
• Adding two isocenter/prone techniques
– Consistent delivery technique
• Changing threshold
– 3 mm to 5 mm
• Examine outliers
– Looking for factors associated
• Replacing ABC with SGRT based evaluation of
breath hold
• Replacing manual SSD with VisionRT

18. Future Directions
• Image guided external beam APBI
– Livi et al- equivalent to WBI
– Recent CCF work
• Cost savings vs. hypofractionated WBI
– Incorporate SGRT into treatment workflow
• Allow for increasingly reproducible set up
• Smaller margins
• Reduction in toxicity

19. Acknowledgments
• Therapists
– Danae McCarthy
– Tracy Palmison
– TruBeam 1 team
– Artiste 2 team
• Dosimetry
• Physics
– Bingqi Guo
– Ping Xia
• Nursing
– Jessica Echle
• Residents and Fellows
• Breast Team
– Rahul Tendulkar
– Sheen Cherian
– Chairman- John Suh

20. QUESTIONS?