Initial Clinical Experience with 3D Surface Image Guidance

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1 Initial Clinical Experience with 3D Surface Image Guidance Amanda Havnen-Smith, Ph.D. Minneapolis Radiation Oncology Ridges Radiation Therapy Center Burnsville, MN April 20 th, 2012

2 Non-funded research collaboration OUTLINE Description of 3D Optical Tracking System and Purpose Use of the System and the Workflow Strengths and Weaknesses of the System TG 147 Recommended Quality Assurance

3 Why use 3D surface image guidance? Can be used for patient set-up and surveillance 3-D Non-Invasive Non-Ionizing

4 Purpose of Surface Image Guidance The goal is to reduce two types of uncertainty in external beam RT Inter-Fraction Give consistency with day-to-day patient setup Intra-Fraction Capability to pause treatment if patient moves out of acceptable position Capability to gate the beam for motion management

5 As EBRT treatments become more conformal, patient positioning and motion management become even more critical! Small errors can be gross errors!

6 Cameras project a red speckle pattern on the surface of the patient, and determine where the patient s surface is in space.

7 Technology Camera Pod Stereoscopic System 3D Surface Information from Image Pair 1) Known Feature Extraction - Structured light projection (speckle pattern) 2) Locate corresponding feature in 2 nd image 3) Compute 3D coords of features using triangulation

8 Software calculates the position of each point along the CT surface with respect to the isocenter Compares the position of all points on the acquired surface (in the Region of Interest) with respect to the planned isocenter Does not directly compare the acquired surface to the planned surface Does not directly account for deformation

9 Do have the option of adding additional ROIs, and you may use centroid method for these - This method compares the weighted centroid of the actual surface to that of the reference surface Strongly recommend using centroid option for objects far from isocenter -For example on a breast patient: chin ROI, arm ROI Strongly recommend not to use the centroid option for primary ROI set-up, system not optimized for this

10 What do we compare the treatment position to? Planning CT Surface (body contour) Ideally our preference Large amount of image data Frame rate is slower Surface can have features not present at treatment Recorded surface in treatment position Faster frame rate for real-time shifts, beam holds Relationship to CT surface is not known

11 Requires attention to the body contour? Wires, Fiducials, Artifacts, etc.

12 WORKFLOW System isocenter calibrated by physics once a month Constancy of iso checked daily by therapists

13 Dosimetrist/Physicist exports data and therapist imports into AlignRT software: Structure Data (dicom RTStructure file) - From this only the Body contour is used Treatment plan for each isocenter (dicom RTPlan file) - Only need to export a single plan if plans have + Same CT image set + Same isocenter

14 Imported Surface & Isocenter

15 ROIs: Functionality largely dependent on ROIs Manufacturer recommends: Not too big T.M.I.! Not too small Not enough info to localize! Works best with well-defined features Does not work as well with fleshy mobile features (large breasts) or highly symmetric features (expanders)

16 It is recommended to include: Breast tissue (if not too pendulous or symmetric) Some axilla/arm Some lower neck/sclav Part of lateral chest wall

17 Patient Setup Line up patient using marks, lasers, SSDs Begin monitoring, use real-time deltas to move patient into correct position Real-time shifts shown for 3 translations, 3 rotations w/in 3 mm and 3 0 (default tolerance) Then initiate treatment Can record treatment surface Can generate a report showing the offsets at any time

18 Treatment Monitoring If patient moves significantly, could pause tx and re-align to plan - Can be helpful for non-compliant patients, can see motion on camera, but did they move back?? If bolus patient, we apply it, then capture new image to monitor motion Motion management tool

19 Deep Inspiration Breath Hold (DIBH) Technique Goal to reduce risk of cardiac toxicity by increasing the distance between heart and breast. Allows IMRT treatment of breast/chest wall

20 DIBH Workflow Acquire free-breathing CT and DIBH CT w/o change in position between scans Treatment plan developed on DIBH CT (can plan a back-up free breathing plan in case system goes down) Both Body surfaces and DIBH plan exported Free-breathe surface is used for rough patient positioning DIBH surface is used to guide patient into position for gated treatment

21 DIBH Workflow Verification simulation performed on the linac prior to initiating treatment Test patient compliance with gated technique Verify ROIs drawn are appropriate for monitoring with gantry angles Patient aligned using lasers, marks, SSDs then realtime deltas using free-breathing surface The surface is then changed to the DIBH surface, monitoring of real-time deltas is initiated and the patient is coached to take a deep breath in until all parameters are within tolerance

22 DIBH Workflow When the patient is at full inspiration Lateral position can be adjusted by moving the table Vertical position is adjusted by asking the patient to breathe more/less Longitudinal position typically also controlled by breath size - Can fine-tune with couch if necessary SSDs/Port films/kv images all acquired during breath hold There is a Coaching display option that is helpful for therapists Displays only Vertical position parameter Bar moves up and down like chest wall, turns from green to yellow when all parameters within tolerance (gating window)

23 DIBH Technique Coaching view with real-time deltas

24 Strengths and Weaknesses Strengths: Non-ionizing Therapists find it to be very useful for setup Faster More efficient, fewer re-ports Intra-fraction monitoring capability Motion management option Can capture charges for image guidance Setup Monitoring

25 Strengths and Weaknesses Weaknesses: ROI selection is very tricky, learning curve Position readouts can become unreliable when gantry interferes in camera line of sight - Especially problematic in gating patients Learning curve for developing troubleshooting techniques The system is very Black Box, requires physicist to develop a thorough QA procedure

26 Strengths and Weaknesses Black Box: Manufacturer s calibrations and constancy checks give only RMS error output TG 147 Report on QA for non-radiographic radiotherapy localization and positioning systems has detailed recommendations

27 TG 147 QA Thorough guidance on commissioning Daily QA Safety & Static Localization Phantom positioned at isocenter and can track movement to isocenter from offset Accuracy should be w/in 2 mm Monthly QA Safety: Gating terminates, Couch motion Static Localization: Localization test based on radiographic analysis (i.e. hidden target test) Dynamic localization: Motion table or manual couch motion of monthly phantom by known distances

28 TG 147 QA Annual QA - Safety: Camera mounting secure Integrity: Check camera settings Stability: Drift Measurement (min 1 hr), reproducibility of localization Static localization: Full end-to-end testing, translation and rotation correct w/in clinical range Dynamic (for gating): Use of motion phantom Data transfer functionality Quality assurance for nonradiographic radiotherapy localization and positioning systems: Report of Task Group 147 Medical Physics, Vol 39, Issue 4

29 Thank You!! Any Questions??

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