The document discusses how Cape Cod Hospital uses AlignRT for motion management from simulation to treatment for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). It describes the equipment, daily quality assurance processes, use of AlignRT for deep inspiration breath hold (DIBH) and surface guided radiation therapy. Examples of AlignRT use for breast, lung, abdominal treatments and SRS planning and delivery are provided.

1. Expert physicians. Quality hospitals. Superior care.
Managing Motion from End to End
Everything from SRS to SBRT with AlignRT
Presented by Gabor Menyhart, Chief Physicist
ASTRO 2015
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Outline
• Equipment
• QA
• Breast etc.
• DIBH (breast, lung, abdominal)
• SBRT
• SRS
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3. Expert physicians. Quality hospitals. Superior care.
AlignRT at Cape Cod Hospital
• AlignRT with TrueBeam in 2011, MMI upgrade in 2015
• AlignRT/GateCT for CT simulations in 2011
• AlignRT for 2nd linac in 2012
• HD camera swap in 2014 for SRS procedures
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4. Expert physicians. Quality hospitals. Superior care.
High Resolution Camera
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5. Expert physicians. Quality hospitals. Superior care.
TrueBeam Treatment Room
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6EX Treatment Room
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CT Simulator Room
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8. Expert physicians. Quality hospitals. Superior care.
Daily QA
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9. Expert physicians. Quality hospitals. Superior care.
Daily QA
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10. Expert physicians. Quality hospitals. Superior care.
Daily QA – TrueBeam Isocal on SBRT and SRS days
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Daily QA – AlignRT IsoCal on SRS Days
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Daily QA – Align RT IsoCal on SRS Days
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Simulation/Treatment – Breast etc.
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• Reconstructed DICOM surface available from scan
• Use for setup and monitoring in treatment room
• Capture reference image a the time of treatment if required

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DIBH Simulation
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• LT Breast and Chest Wall
• Coach patient (scan vs beam on time)
• Free breathe and breath hold scans captured
• No need for camera unless breath hold is being monitored

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DIBH Treatment
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• Setup patient using free breathe DICOM surface
• Switch to Breath Hold surface and verify breath hold
• Use coaching screen if needed

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4D/SBRT Simulation
• Immobilization devices (SBRT, vaclock bag, lung board only)
• Patient coaching for 4D sim
• Lighting conditions for proper surface capture, skin tone
• Identify appropriate Tracking Patch
• Determine breathing period
• Determine if 4D is usable or DIBH is necessary
• 4D QA using phantom monthly and annual end-to-end testing
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17. Expert physicians. Quality hospitals. Superior care.
4D/SBRT Simulation
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18. Expert physicians. Quality hospitals. Superior care.
4D/SBRT Simulation
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19. Expert physicians. Quality hospitals. Superior care.
4D/SBRT Simulation
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20. Expert physicians. Quality hospitals. Superior care.
Free Breathe or DIBH
• After 4D simulation tumor motion was determined to be more
than 1cm
• Attempted simulation with compression belt, but not enough
surface information to reconstruct tumor motion
• Capture free breathe and DIBH scan (possible to choose breath
hold phase after 4D scan based on binning)
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21. Expert physicians. Quality hospitals. Superior care.
Treatment Planning
• ITV is contoured on MIP (tumor volume is contoured on
individual phases if attached to structure)
• Normal structures contoured on average image set
• VMAT, 6XFFF, 3 arcs
• Planner transfers information to AlignRT workstation
• Therapists import information and create ROI
• Physicist reviews ROI before delivery
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22. Expert physicians. Quality hospitals. Superior care.
SBRT Plan
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Free Breathe Treatment Delivery
• DICOM surface for initial setup
• CBCT
• Acquire Gated Reference Surface after shifts
• Monitor throughout treatment
• Repeat CBCT if needed
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24. Expert physicians. Quality hospitals. Superior care.
DIBH Treatment Delivery
• Setup patient using Free Breathe DICOM structure
• Verify breath hold using DIBH DICOM
• Perform CBCT with DIBH
• After CBCT analysis, breath hold, shift, re-capture, breathe
• Treat using the newly captured DIBH reference surface
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25. Expert physicians. Quality hospitals. Superior care.
SBRT Treatment
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26. Expert physicians. Quality hospitals. Superior care.
SRS Simulation
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SRS SIMT Plan
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28. Expert physicians. Quality hospitals. Superior care.
SRS Treatment
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29. Expert physicians. Quality hospitals. Superior care.
SRS Treatment
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30. Expert physicians. Quality hospitals. Superior care.
SRS Treatment
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31. Expert physicians. Quality hospitals. Superior care.
SRS Treatment
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32. Expert physicians. Quality hospitals. Superior care.
Conclusion
• AlignRT is a great solution to decrease setup and imaging times
• Monitoring during treatment is very reassuring
• Staff confidence develops rapidly
• Use for setup and DIBH
• Starting/expanding SBRT/SRS program follows
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33. Expert physicians. Quality hospitals. Superior care.
Thank you
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