SGRT Europe 2022 Lydia Kedziorek Principal Treatment Superintendent Royal Derby Hospital, England Full video at SGRT.org

1. How to Go-Live with
Tattoo and Mark Free Treatments
Lydia Kedziorek
Royal Derby Hospital
Principal Treatment Lead

2. Royal Derby Hospital
• 4 Varian Truebeam
Linear Accelerators
• 1 Philips Big Bore CT
with Gate CT
• 1 Xstrahl superficial unit
• HDR brachytherapy
• ARIA
• SGRT on 2 linacs –
AlignRT Advance (6.3)

3. Our Department Goals
• To improve our DIBH technique
• Enable a safe introduction of SABR treatments
• Offer tattoo and mark free treatments as soon as
possible for all types of breast treatments (from day 1 of
implementation)
Introduction

4. 1. The importance of tattoo and mark free treatments
2. The training processes we followed to enable tattoo
and mark free treatments
3. QA and Quality procedures adopted to achieve this
4. Results, outcomes and tips for success for other clinics
Objectives

5. • On average - 500 breast patients referred each year
• Old technique:
- 3 tattoos (anterior and laterals)
• Voluntary DIBH - marks drawn in surgical marker
• Field borders marked in surgical marker, field light checked
against these
• Patient complaints > consent to tattoos done for every
patient
Tattoo and Marks
for Breast Radiotherapy

6. The importance of tattoo and mark
free treatments
Some key findings in the study were:
•70% had negative feelings about this
involuntary body modification
•78% of patients would choose a
treatment which avoided tattoos and/or
marks
•45 miles is the average additional
distance patients are willing to travel to
a centre that is tattooless/markless

7. Our Patient’s Perspective
Getting tattooed sort of
punctuated that feeling of
being out of control. I know
that, in the grand scheme of
things, it is simply a few
teenie-tiny little dots, but it
is a daily, physical reminder
that I had stage 3 cancer -
and that there was no time
to really consider the
options.
They are a reminder of
times I'd rather forget -
it's a constant reminder
of the treatment and
traumatic time.

8. Our Patient’s Perspective
In Japan’s history, criminals
in jail were tattooed so they
could be easily identified.
There are still certain areas
of Japan where you would
not be allowed with tattoos
as it still scares people.
The thought of having
tattoos mentally tortured
me.
Buying clothes afterwards was
frustrating as lower cut tops were
in fashion - even now I have to be
very careful to make sure the spot
doesn't show so I don't get asked
questions about it.

9. • Theory and practical sessions with
the Clinical Applications Specialist
• Vision RT Portal – training modules
• Training package created for staff
using resources from the portal
Our Training

10. • Created treatment protocols
using resources from the
Vision RT training portal
Staff Training
• Created test patients within
Align RT for Region of Interest
(ROI) training

11. • DIBH workflow
• Difficult set ups
Practical Training Sessions

12. Quality Procedures
End to End Testing
• Anthropomorphic phantom
• CT Scan / plan
• Export/Import protocol
created
• Staff practical sessions using
SGRT, image and treat

13. End to End Testing
• Allowed staff to get used to the
system

14. End to End Testing
Gave us
confidence

15. • By following a clear training and testing programme we were able to meet
our objectives of go live for DIBH SGRT treatments on day 1 of
implementation
• DIBH much more accurate – staff members could see the benefit
• Had to be much more stringent with those eligible for DIBH – CT had to
change process slightly
• Feedback from both patients and staff has been extremely positive
• Patients travelling further to receive tattoo free treatments
• Now offering tattoo free treatments to more sites
Results

16. • ROI Training Vital
• Spent time working out the best ROIs for us. Not one
fits all – assess on day 1
Tips for Success …

17. • Gain experience with problem solving:
- 1 second beam delay
- Change of skin tone
-Editing ROIs during treatment
• ‘Super users’ to support with challenging patients
• Access support from the SGRT community forums
Tips for success…

18. • Pendulous breasts –
challenging but found
PV helps
• Thorax patients – 1 arm
down
Utilise Postural Video (PV)
• Palliative patients

19. • Lung SABR
• Oligometasases SABR – Pelvic patients
• Lymphoma Abdomen (DIBH)
• Palliative sites i.e. humerus, SCF
• All thorax patients (Jan 2023)
Further Tattoo Free Treatments

20. Any Questions?