SGRT USA 2021 Presentation by Snehal Desai, MD​ Radiation Oncologist​ Houston Methodist Hospital​ Houston, TX

1. How Centers Can
Thrive in the Modern Era
Snehal Desai, MD
Radiation Oncologist
Houston Methodist Hospital
Houston, TX

2. Disclosures NONE

3. How should we prepare for the future?
 Evidenced based medicine
 Quality care for cancer patients
 Hypofractionation/SBRT – breast/prostate/rectal/lung cancer
 increases risk from patient motion
 Consider technology not for increased revenue but to minimize
post-treatment costs

4. Advances in Radiation Therapy
Intent
Intent
‘Actual’
4-field box CRT 3D-CRT IG-IMRT
Intent
Intent
‘Actual’
4-field box CRT 3D-CRT IG-IMRT
SGRT

5. Surface Guided Radiation Therapy:: SGRT
Patient Setup:
• Non-invasive, non-ionizing, 3D, real time
• Accurate postural and isocentric setup
(accuracy* ≤0.3 mm / ≤0.2°)
Intrafraction Monitoring:
• 6DOF motion monitored in real time with no dose
• Automatically beam hold when patient motion exceeds
a preset threshold
1
2
• Generates a surface of the patient using 3 camera pods
• Matches the live surface in real time to a reference image

7. Where does SGRT fit in?
We, as providers, continue to demand innovation
that produces better clinical outcomes
Emerging
Trends
Total Cost
of Care
Quality
Outcomes
Patient
Experience
Shared Decision
Making
Center
Needs
Efficient, reduced costs,
strong data integration,
mitigation of adverse events
Safe, effective,
reduced toxicity,
evidence based care
Satisfaction
and comfort
Engaging patients in treatment
decision making – considering
cost and goals

8. Complex
Intermediate
Simple
Intracranial
SRS
(mets)
DIBH SBRT
Standard
Breast
Pelvis
Extremities
GI
DIBH Left
Breast
SBRT
Lung
SBRT
Liver
Palliative
Prone
Breast
Trigem
H&N
Partial
Brain
Brain
GYN
SBRT
Spine
SRT
H&N
Acoustic
Utilization of SGRT

9. Verification of daily setup consistency is done with weekly imaging.
In certain circumstances, more frequent imaging may be appropriate.
Routine use of daily imaging is not recommended.
The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical
physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic
services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists,
medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the science
of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards will be reviewed
for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been
subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic and therapeutic
radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice parameter and
technical standard by those entities not providing these services is not authorized.
Revised 2019 (CSC/BOC)*
ACR–ASTRO PRACTICE PARAMETER FOR IMAGE-GUIDED RADIATION
THERAPY (IGRT)
PREAMBLE
This document is an educational tool designed to assist practitioners in providing appropriate radiation oncology care
for patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth below,
the American College of Radiology and our collaborating medical specialty societies caution against the use of these
documents in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this

10. Breast Setup without
imaging
 Improved Daily Setup
 Correct postural setup
 Decreased setup times
 Analysis tools – SSD, Setup Quality
 Decreased imaging exposure to patients
Total Cost
of Care
Patient
Experience
Quality
Outcomes

11. 11
Herron E, et al. Surface guided radiation therapy as a replacement for patient marks
in treatment of breast cancer. Int J Radiat Oncol Biol Phys. 2018; 102 (3):e492-e493.
Improving patient throughput and decrease staffing
costs (overtime)
250-fraction study: 14% reduction in setup time / fraction, with reduced time variability
SGRT vs Marks Setup Times SGRT vs Marks Shifts / SSD
Total Cost
of Care
Patient
Experience

12. Clinical Benefit:
Decreasing long term side effects
Deep Inspiration breath hold - Left Breast
• Multiple peer-reviewed publications
• Reproduces consistent inspirations - uniform distance from the
heart to the chest wall
• Eliminates need for physical devices on the patient
Prevented cardiac perfusion defects in 100% of
patients studied2,3
Data
Cardiac perfusion defects at 6 months
as measured using SPECT imaging
30%
25%
20%
15%
10%
5%
0%
Traditional
Treatment3
Using AlignRT
and DIBH2
27% vs. 0%
Total Cost
of Care
Patient
Experience
Quality
Outcomes
Shared
Decision
Making

13. Clinical benefits in radiosurgery
SRS
• Published and Peer-reviewed publications - outcomes
similar accuracy to frame with open face mask and SGRT
• Trigeminal neuralgia
• Single Iso Multiple Mets
• Nonionizing imaging for preliminary set-up, prior to cone
beam imaging
• Faster delivery – no repeat imaging between couch kicks
• Less invasive open mask enhances patient comfort vs frame
• Real time tracking of patient regardless of couch angle
• Improved patient comfort – no frame or closed mask
5-year data on benign lesions showing
excellent outcomes16
Data Total Cost
of Care
Patient
Experience
Quality
Outcomes

14. 8
weeks
8
weeks
Hypofractionation – higher dose with
fewer treatments
 Breast Hypofractionation
 Prostate Hypofractionation
 Prostate SBRT
 Lung SBRT/Hypofractionation
 Rectal Hypofractionation
4
weeks
6
weeks
4
weeks
2
weeks
2
weeks
6
weeks
5.5
weeks
2
weeks

15. Hypofractionate with confidence
Hypofractionation/SBRT
• Accurate initial positioning
• Patients move - Continual motion management
to detect intrafraction motion
• Reduces setup time, including CBCT shifts
Patients move during treatment.
AlignRT can detect clinically meaningful intrafraction
motion.
Data Total Cost
of Care
Patient
Experience
Quality
Outcomes

16. Safety - Identifying
treatment changes
 Identified on AlignRT
 On demand CBCT on LINAC to verify issue
 Patient resimulated after seen by plastic surgery
Total Cost
of Care
Quality
Outcomes

17. Safety -
Setup error
identified
Total Cost
of Care
Quality
Outcomes

18. Mitigation of adverse events
Type Description AlignRT
Wrong Patient
Treated
Two patients with the same last name/ One for a rectal cancer in
prone position, treated with plan from prostate cancer supine
position patient

Wrong Patient
The treatment room was prepared for a particular patient, but a
student brought through the wrong patient. 
Accessory
Missing
Bolus left off for one fraction in error. 
Wrong Accessory
1cm of bolus was used on a left lateral electron boost field
instead of 0.5cm bolus on the patient's last day of treatment. 
Wrong Site
Instead of the left knee, the right knee was irradiated for one
fraction 
Wrong tattoo Radiographers used wrong tattoo to set up supraclav field. 
Setup Error
There was a miscommunication regarding shifts required to line
up patient treatment fields properly. 
Total Cost
of Care
Quality
Outcomes
50% of reported near misses / medical events at the time of treatment could have been prevented.

19. Tattooless –
Eliminates Marks
Tattoos typically are used for 3-point setup;
however these marks can be far from
TxIsocenter
Patients report that these tattoos serve as a
constant reminder of their cancer treatment
Invisible tattoos can mitigate the psychosocial
effects of skin marks
In a recent study, patients and survivors shared the following:
78% of Patients
WOULD PREFER A TATTOOLESS OPTION
Patients are willing to travel 45 Miles
TO GO TO A TATTOOLESS TREATMENT CENTER
Patient
Experience
Quality
Outcomes
Shared
Decision
Making

20. SGRT post implementation analysis
 Standardization across a wide array of body site
 Improve current treatment process
 Treatment monitoring/Gating
 DIBH
 Frameless SRS
 Evaluate our treatment process
 Quality of immobilization
 Treatment margins
 Can be used to minimize imaging exposure
 Correct postural setup prior to IGRT
Total Cost
of Care
Patient
Experience
Quality
Outcomes
Shared
Decision
Making

21. Thank you!

22. Questions
 Where does SGRT fit it?
 Total Cost of Care
 Quality Outcomes
 Patient Experience
 Shared Decision Making
 All of the Above
 Answer All of the Above

23. Questions
 SGRT can potentially minimize adverse treatment events ?
 Wrong patient treated
 Missing accessory
 Wrong Site
 Setup Error
 All of the Above
 Answer All of the Above

24. Questions
 The use of SGRT is supported by
 Evidence based papers
 ASTRO/ACR white papers
 SGRT Community
 All of the Above
 Answer All of the Above

25. Questions
 SGRT can improve setup and reduce need for imaging?
 TRUE
 FALSE
 TRUE

26. Questions
 SGRT is only beneficial for breast treatments?
 TRUE
 FALSE
 FALSE – SGRT can be used for every body site and for all treatments