SGRT Europe 2022 Karen McGoldrick Clinical Lead Radiation Therapist Peter MacCallum Cancer Centre -Moorabbin Campus, Australia

1. We can see clearly now:
Implementation of
surface guided
radiotherapy
Karen McGoldrick

2. PETER MAC MOORABBIN

3. SURFACE GUIDANCE BEGINS
• Feb 2022 – 1st SGRT installed on our TrueBeam with 6DoF
• Installation
• Commissioning
• Go-Live – Monday 21st February 2022

4. IMPLEMENTATION - TRAINING
• Training consisted of 2 components:
a) Online learning modules :
• In-service recorded video presentation by AlignRT
• Online modules on VisionRT portal
• Review of additional resources on Peter Mac online learning platform (LMS)
b) Hands on Training:
• QA processes
• Plan Preparation
• ROI tips
• Phantom run through of workflows for: Breast, DIBH Breast, Electrons
• Clarification of set up and treatment surfaces

5. IMPLEMENTATION – CASE SELECTION PHASE 1
• DIBH Breast – offer tattoo free treatment - 10 per day
• DIBH Haematology – Mediastinal Region - infrequent
• Breast VMAT – complex nodal volumes including IM – 1 per day
• Sarcoma Extremities – 2 per day
• Neuro SRS – 1 per week
• ~ 50% of linac patient load per day

6. NEURO SRS – OPEN FACED MASKS
White dual layer Black dual layer
Blue – single layer

7. NEURO SRS – OPEN FACED MASKS
CDRTM Stabilisation:
- FreedomX board
- Personalised head & Neck foam support using intuition click
- CDR Open Faced Mask

8. • Initial patient positioning closer to planned position
• Post CBCT Reference capture for patient monitoring throughout
treatment
NEURO SRS – OPEN FACED MASKS

9. COMPARISON OF INTRAFRACTION IMAGING
MATCH FOR CLOSED VS OPEN FACED MASKS
Courtesy: J Hughes PMCC 2022

10. COMPARISON OF FREQUENCY OF
INTRAFRACTION SHIFTS FOR CLOSED VS OPEN
FACED MASKS
Courtesy: J Hughes PMCC 2022

11. SURFACE GUIDANCE EXPANDS
• July 2022 – 2nd SGRT installed on our a newly commissioned TrueBeam with 6DoF

12. IMPLEMENTATION – CASE SELECTION PHASE 2
PRIORITY CASES:
• All Breast cases -tattoo free treatment for all these patients
• DIBH Haematology – Mediastinal Region
• EBH Liver SABR - using RPM for CBCT Gating and motion management
& AlignRT for patient positioning and motion management
• All Extremities - limbs
• Neuro SRS
• SABR – except those that require phase gated RT
OPTIONAL CASES:
• All Thorax cases – Lung, Esophagus, Mediastinal
• Palliative cases

13. UNUSUAL CASES – MR M - H&N WITHOUT MASK
• H&N patient
• Unable to tolerate mask, originally palliative intent
• Changed to radical dose 70Gy in 35 #
• SGRT – setup & monitoring

14. MR M

15. MR M
• IGRT Shifts from initial Setup Surface prior to treatment

16. MR M

17. EBH LIVER SABR
Using RPM & AlignRT
concurrently
Advantage of RPM:
I. Able to employ Gated imaging to
ensure CBCT only captured in EBH
II. Previous confidence in RPM for
motion management
Advantage of AlignRT:
I. Increased set up accuracy prior to
CBCT
II. Surface tracking entire region, not
just the abdomen to ensure
patient position remains consistent

18. DIBH
Using RPM &
AlignRT
concurrently
Advantage of RPM:
I. Able to employ
Gated imaging to
ensure CBCT only
captured in EBH
II. Previous
confidence in
RPM for motion
management
Advantage of AlignRT:
I. Increased set up accuracy prior to CBCT
II. Surface tracking of treatment region, in this case
the sternum to ensure patient position remains
consistent in DIBH

19. NO LIMB LEFT UNTURNED
• SGRT a total game changer for managing extremities
• Enormous benefit by enabling pitch , rotation & roll to be corrected prior to
IGRT
• CBCT with match using 6DoF = increased accuracy of treatment delivery

20. SARCOMA – POSTERIOR THIGH

21. SARCOMA – POSTERIOR THIGH

22. SARCOMA – ANTERIOR KNEE

23. SARCOMA – ANTERIOR KNEE

24. SARCOMA – ANTERIOR KNEE
mm
-15
-10
-5
0
5
10
TRANSLATIONAL SHIFTS
LAT LONG VERT
degrees
-5
-4
-3
-2
-1
0
1
2
ROTATIONAL SHIFTS
PITCH ROLL RTN
IGRT Shifts from initial Setup Surface prior to treatment

25. SINCE IMPLEMENTATION
• New starts – 211
• Over 2500 treatments delivered with SGRT
• Over 120 Breast patients offered tattoo free treatment
• 62 Moorabbin Campus staff completed Online Learning modules and hands on
training
STAFF FEEDBACK:
• Less manual handling
• Works well for extremities
• Very good for DIBH Breast treatments

26. NEXT STEPS
• Continue to analyse SGRT Vs IGRT shifts for SRS treatments to
determine if we can reduce intrafraction imaging if SGRT with tolerance
• Review literature to inform open face mask implementation for radical
H&N treatments
• Prepare all campuses to move to SGRT for all patients and become
tattoo free

27. ACKNOWLEDGEMENTS
• Moorabbin MDT including Moorabbin RT Team & Moorabbin Physics Team

28. IMPLEMENTATION -DEFINITIONS
SGRT_SURFACE
• SGRT_Surface is always the 1st reference surface to set up the patient with AlignRT
• RTs were instructed to use default Search Body settings ensuring VOI has been
reviewed to cover relevant section of the patient anatomy

29. IMPLEMENTATION -DEFINITIONS
Additional structures to be created in TPS that are
exported with the approved plan to AlignRT.
The additional contours are :
• SGRT_BOLUS = patient surface added to bolus
structure – used for treatment surface to ensure
bolus correctly placed
• SGRT_BH = same as SGRT_Surface (HU = -700)
but contoured on the deep inspiration breath-
hold data set for all plans with motion
management – used for treatment surface in
DIBH plans
• SGRT_BH + BOLUS = same as SGRT_BOLUS but
added to the deep inspiration breath-hold data
set for all plans with DIBH and bolus – not used
currently due to limitation of 2 surfaces per plan
but referred to if concerns bolus fits incorrectly
• SGRT_ELECTRON = copy of SGRT_Surface -
required for all electron plans sent to AlignRT –
allows for different ROI for treatment
monitoring
SGRT_BOLUS