The document outlines the implementation of surface guided radiation therapy (SGRT) for left breast deep inspiration breath hold (DIBH) treatments, detailing practical considerations, system implementation, and patient treatment planning. Key elements include proper patient evaluation, equipment setup, and workflow to maximize reproducibility and treatment efficiency. The process is deemed scalable and effective, utilizing Varian TrueBeam and VisionRT technology.

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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!