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Work role & Dynamic Responsibilities of Radiation Therapists & PTV Margin Concept

Administering radiation therapies as per patient treatment plans. Using medical imaging equipment to ensure treatments are delivered accurately. Assessing patients' reactions to treatments, providing advice on the side effects of treatments, and methods of alleviating these.

1 of 22
Subrata Roy
Senior Radiation Therapist
Hcg-Ics Khubchandani Cancer Centre, Mumbai
Workrole & Dynamic Responsibilities of
Radiation Therapists & PTV Margin
Concept
Radiation Therapists Overview
Learning Curves of Radiation Therapists
Career Progress & Advanced Practice Roles
Artificial Intelligence Competency in RTT workflow
RTT Treatment delivery Risk Management Strategies
Concepts of PTV Margin
Conclusions & References
FLOW OF
PRESENTATION
Radiation Therapists Overview
IMMOBILIZATION
PRE
TREATMENT
COUNSELLING
CT
SIMULATION
PRECISE
TREATMENT
DELIVERY
TREATMENT
MONITORING
SIDE EFFECT
MONITORING
VERIFYING
THE DOSE
PARAMETERS
RESEARCH &
DEVELOPMENT
IMAGE
VERIFICATION
Learning Curves of Radiation Therapists
The Technological advancement for the cancer patients and Radiation therapy services
demands changes and evolution of the roles of Radiation Therapist.
Through the decades the primary challenges in radiotherapy treatment aimed at how to
ensure the beam reaching the tumour as planned and how to minimize the dose to the
normal structures.
Skills & Knowledge required to become an Outstanding Radiation Therapist
Radiation therapists should be well-oriented. Depending on local policy this may include
radiotherapy planning, treatment delivery, clinical and psychosocial care of the patient on
daily basis during treatment and immediate post treatment review.
As the professional in daily contact with the patient it also includes monitoring of side effects and appropriate referral.
Path of Improvising into Advanced practice Role
Career Progress & Advanced Practice Roles
Clinical
Therapy Area
Site Specific
Specialization
Head & Neck
Lung / Motion
Management
Prostate Or Urology
Intra Cranial
Brachy Therapy
Pediatric Treatment
Palliative Care
SRS & SABR Treatment
On
Treatment
Review
Image
Review
Advise For
Physiological
Counselling
Pre
Treatment
Counselling
Support &
Information
Monitoring the
Side Effects
Clinical
Education
Clinical Research
Practice
Development
Artificial Intelligence (AI) Competency in RTT workflow
AI has the potential to reduce time and inter-observer variability and increase accuracy in the
delivery of radiation therapy. It is important to consider what skill requirements may change for
Radiation Therapists, dosimetrists, Medical physicists and Radiation oncologists.
Artificial Intelligence working
Mechanism
Need Cross Verification and Level of Authentic care and confirmation
required from RTT side to Proceed for high dose Delivery .

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Work role & Dynamic Responsibilities of Radiation Therapists & PTV Margin Concept

  • 1. Subrata Roy Senior Radiation Therapist Hcg-Ics Khubchandani Cancer Centre, Mumbai Workrole & Dynamic Responsibilities of Radiation Therapists & PTV Margin Concept
  • 2. Radiation Therapists Overview Learning Curves of Radiation Therapists Career Progress & Advanced Practice Roles Artificial Intelligence Competency in RTT workflow RTT Treatment delivery Risk Management Strategies Concepts of PTV Margin Conclusions & References FLOW OF PRESENTATION
  • 3. Radiation Therapists Overview IMMOBILIZATION PRE TREATMENT COUNSELLING CT SIMULATION PRECISE TREATMENT DELIVERY TREATMENT MONITORING SIDE EFFECT MONITORING VERIFYING THE DOSE PARAMETERS RESEARCH & DEVELOPMENT IMAGE VERIFICATION
  • 4. Learning Curves of Radiation Therapists The Technological advancement for the cancer patients and Radiation therapy services demands changes and evolution of the roles of Radiation Therapist. Through the decades the primary challenges in radiotherapy treatment aimed at how to ensure the beam reaching the tumour as planned and how to minimize the dose to the normal structures. Skills & Knowledge required to become an Outstanding Radiation Therapist Radiation therapists should be well-oriented. Depending on local policy this may include radiotherapy planning, treatment delivery, clinical and psychosocial care of the patient on daily basis during treatment and immediate post treatment review. As the professional in daily contact with the patient it also includes monitoring of side effects and appropriate referral. Path of Improvising into Advanced practice Role
  • 5. Career Progress & Advanced Practice Roles Clinical Therapy Area Site Specific Specialization Head & Neck Lung / Motion Management Prostate Or Urology Intra Cranial Brachy Therapy Pediatric Treatment Palliative Care SRS & SABR Treatment On Treatment Review Image Review Advise For Physiological Counselling Pre Treatment Counselling Support & Information Monitoring the Side Effects Clinical Education Clinical Research Practice Development
  • 6. Artificial Intelligence (AI) Competency in RTT workflow AI has the potential to reduce time and inter-observer variability and increase accuracy in the delivery of radiation therapy. It is important to consider what skill requirements may change for Radiation Therapists, dosimetrists, Medical physicists and Radiation oncologists. Artificial Intelligence working Mechanism Need Cross Verification and Level of Authentic care and confirmation required from RTT side to Proceed for high dose Delivery .
  • 7. My Published Newsletter on ESTRO RTT track about the “Understanding the utility of artificial intelligence in Radiation Oncology”
  • 8. RTT Treatment delivery Risk Management Strategies The process of Radiotherapy is complex and involves understanding of the principles of medical physics, radiobiology, radiation safety, dosimetry, radiotherapy planning, simulation and interaction of radiation therapy with other treatment modalities. Health professionals involved in the delivery of radiation treatment are the Radiation Oncologists (RO), Radiation Therapists (RTT) and Medical Physicists (MP). Each of these disciplines work through an integrated process to plan and deliver radiotherapy to patients.  Radiotherapy Treatment is purely a multidisciplinary action.  Accidental exposures in radiotherapy may result from an accident, an event or a sequence of events, including equipment failures and operating errors.
  • 9. • Equipment quality assurance to reduce the risk of systematic errors such as miss calibration that may affect very large numbers of patients. • Peer review audit to improve decision making that will have flow-on effects throughout the treatment process. In addition there are safety processes that apply to all stages of the delivery of Radiotherapy:- 1. Patient identification 2. Audit of equipment commissioning 3. Staff competency assessment 4. Process and equipment quality assurance 5. Process governance 6. Error reporting and quality improvement 7. External checking 8. Adequate staffing Risk factors associated with Radiotherapy treatment delivery :--
  • 10. Delivering and maintaining good quality radiotherapy also implies strong efforts to reduce risks and to prevent adverse error-events i.e quality management. Quality management done by traditional tools such as quality assurance, quality control and quality audit therefore it’s corner stone for all preventive measures. In the terminology used in these guidelines risk means “Radiation Risk”—that is, risk of all the various ways in which a patient could be harmed in the context of using radiation for the treatment, which is considered to be an adverse error-event. Risk Management The concept of risk covers many details of the radiotherapy procedure, such as incorrect patient positioning or poorly-managed unscheduled interruptions, both of which can negatively impact treatment outcomes. Risks for treatment-related side effects are undoubtedly important, this wider concept is not included here because it is unrelated to any treatment errors.
  • 11. Modern Radiation Therapists involves in all the vital Steps of Radiotherapy Treatment preparation . Hence Therapist can cross check and plays a major role to rectify, identify and formulate the Safety protocols in better way to reduce the Risk Profiles for the Patients and as well as for the radiation workers. These are the Following Steps Where radiation Therapists can take a stand and give useful inputs which can leads into better Risk free Radiation delivery:- 1. Immobilization or Mould Preparation 2. Acquiring the CT scan with Pre seted Protocol 3. Precise Treatment Delivery Areas where Clinical Radiation Therapists can take a stand
  • 12. Concepts of PTV Margin 1) Gross tumor volume or GTV 2) Clinical target volume or CTV 3) Planning target volume or PTV 4) Organ at risk or OAR 5) Planning organ-at-risk volume or PRV 6) Internal target volume or ITV 7) Treated volume or TV 8) Remaining volume at risk or RVR Source: As introduced in ICRU Reports 50, 62, 71, and 78 (ICRU, 1993; 1999; 2004; 2007), several volumes related to both tumor and normal tissues have been defined for use in the treatment-planning and reporting processes. GTV CTV PTV ?
  • 14.  The Radiotherapy PTV encloses the CTV with anisotropic margins to account for possible uncertainties in beam alignment, patient positioning, organ motion and organ deformation.  Ideally, the CTV-PTV margin should be determined solely by the magnitudes of the uncertainties involved.  Clinician usually also considers doses to abutting healthy tissues when deciding on the size of the CTV-PTV margin. The international commission for radiation units and measurement (ICRU) has provided a common language for physicians and physicists to plan and evaluate their treatments.
  • 15. This concept is integrated in the inverse planning process and minimizes deviations to planned dose distribution through integration of uncertainties in the planning objectives. The PTV concept has been used for more than two decades but is becoming obsolete as the CTV-to-PTV margin creates a static dose cloud that does not properly recapitulate all planning vs. delivery uncertainties. The robust optimization concept has recently emerged to overcome the limitations of the PTV concept.
  • 16. PTV is a geometrical concept, introduced for treatment planning and evaluation. It is the recommended tool to shape dose distributions that ensure with a clinically acceptable probability that an adequate dose will actually be delivered to all parts of the CTV... Include both “internal” and “external” variations of the CTV Separate delineation of the ITV is not necessary but motion should be included in the PTV  CTV to PTV margin recipe based on random and systematic errors, and beam penumbra,  Priority rules when overlapping PTVs or PTV-PRV,  Dose is prescribed and reported on the PTV.  IMRT can result in hot and cold spots within the PTV.
  • 17. Required Margins The margins, in their simplest form, are simply expansions to the shape of a treatment beam, to ensure that dosimetric planning criteria are met in the presence of inter- and intra-fraction setup variations The PTV allows for uncertainties in planning or treatment delivery, and is designed to ensure that the radiotherapy dose is actually delivery to the CTV. The PTV is a geometric concept designed to ensure adequate dose coverage to CTV
  • 18. Additional sparing of adjoining healthy structures should be accomplished by modifying beam portals, rather than adjusting the PTV. PTV is determined by adding margin to the CTV to account for internal target volume and patient motion, and the field margins are set to confirm to the PTV with allowance for the RT beam penumbra and dose build-up effect. The van Hark formula (PTV margin =2.5Σ +0.7σ) (2.5 X SD of group of Systematic Error) + (0.7 X SD of Random Error) Ensures CTV should receive 95% of the Prescribed dose Systematic Error: Influences all fractions in Identical way throughout the treatment. Random Error: Influences fractions randomly Source: Van Herk et al. IJROBP, 47: 1121-35,2000
  • 19. Institutional Protocol Rationales Radixact Tomotherapy Cyberknife VSI CTV-PTV Margin PTV Margin- 5mm PTV Margin- 1mm Daily Pre Treatment Imaging Modality MVCT ( 3.5 MV) 2D Orthogonal X-ray Imaging Frequency of Imaging IGRT – Daily Imaging (MVCT) IMRT- Weekly thrice 3DCRT- Weekly Twice Deals with Live kV-X-ray Intrafraction Imaging System.( 5-150 sec) Selection of Immobilization Devices All site specific orfits & for Thoracic & Pelvis Cases Vaclok preferably used . All Sites with Vaclok Immobilization except the Intracranial Lesions. (U – Frame Thermoplastic Mould)
  • 20. Conclusions & References We came a long way from Conventional box field treatments to advanced high dose Stereotactic Radiosurgery treatment delivery with the help of various technical approaches,  The role of Radiation Therapist is increasing with increasing precision metamorphosis of RTT  Constant updating of knowledge and New technology is very much essential.  The role of AI (Artificial Intelligence) in field of radiation is evolving but presence RTT is always needed.
  • 21.  ICRU Report 50—Prescribing, Recording and Reporting Photon Beam Therapy. [Online] American Association of Physicists in Medicine; 1994, 833–834. Available from: doi: 10.1118/1.597396 Google Scholar  Gregoire, V, Mackie, T R. Dose prescription, reporting and recording in intensity-modulated radiation therapy: a digest of the ICRU Report 83. London: Future Medicine Ltd; 2011;3(3): 367–373. Available from: doi: 10.2217/iim.11.22CrossRefGoogle Scholar  Gill, S K, Reddy, K, Campbell, N, Chen, C, Pearson, D. Determination of optimal PTV margin for patients receiving CBCT-guided prostate IMRT: comparative analysis based on CBCT dose calculation with four different margins. United States: Wiley; 2015;16(6): 252–262. Available from: doi: 10.1120/jacmp.v16i6.5691 CrossRefGoogle Scholar
  • 22. For your Kind Attention Cancer may have started the fight ,But I will finish it

Editor's Notes

  1. Modern Radiotherapy Techniques Like SRS SBRT SRS incorporates with complex Planning Parameters, Optimization and several setup Uncertainties Which may leads into various Errors. SRS SBRT technique includes very high amount dose to be delivered in single or in Multiple Fraction SBRT SRS cases includes more steps to conformity and complex geometry which is generating more risks if not handled in Proper way