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The SBRT Ch ∞ in

The SBRT Ch ∞ in. Introduction to the Complexities of SBRT delivery. THE SBRT CHAIN Introduction to the Complexities of SBRT. Daniel Tan Course Director Associate Consultant Department of Radiation Oncology National Cancer Centre Singapore. The SBRT Ch ∞ in.

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The SBRT Ch ∞ in

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  1. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery THE SBRT CHAIN Introduction to the Complexities of SBRT Daniel Tan Course Director Associate Consultant Department of Radiation Oncology National Cancer Centre Singapore

  2. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Aims: Provide a Basic Overview of the SBRT Process Set Context for Subsequent Talks Demonstrate the Importance of Each Link Deliver some Take Home Messages

  3. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery WHAT IS SBRT: STEREOTACTIC- a procedure during which a target lesion is localized relative to a know three dimensional reference system. SBRT is a specialized form of Cancer treatment whereby high doses of radiation are delivered in large fraction sizes over a short course of treatment

  4. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery WHAT IS SBRT: By accurately Localizing the target through imaging and immobilization, and creating highly conformal doses around the target, with steep dose gradients outside of it, extremely high doses of ablative radiation can be delivered to the target with minimal side effects to normal tissue.

  5. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery It is a Different Kind of Operation with the Same Objective of exterminating the enemy with minimal collateral losses

  6. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Not an Issue of Good or Bad – Just Different Different Approaches are required In Oncology

  7. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery

  8. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery

  9. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery SBRT leverages on Technology to exploit the therapeutic ratio afforded by a highly conformal dose distribution and steep dose gradients around an accurately localized target All the bells and whistles are really only to achieve the above. Of course the optimal dose fractional matters, but we are talking about delivery here. Since we are depending on technology and processes to achieve our therapeutic goals, we need to master them to delivery good SBRT

  10. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery The greater the capability,The higher the complexity The higher the complexity, The larger the number of steps and the greater the skills required The larger the number of steps, The more people are involved The more people are involved, More coordination is needed The greater the skills required, More training is needed To ensure the whole system functions, it actually needs to be tested as a whole and not just individual components.

  11. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Basic: Clinical Setup- Logistical, Manpower For accurate diagnosis, imaging, pathology and staging For discussion and decision of a sound treatment plan Multi-Disciplinary Framework- National, Institutional, Sub-groups evidence-based guidelines/protocols for each specific cancer and stage.

  12. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Basic Radiation Oncology Facility: Adequate Equipment Adequate Manpower Adequate Expertise Adequate Systems Adequate Support 1D – 2D – 3D – IMRT – 4D – SBRT Can we actually skip these steps?

  13. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Getting There: Modifying Existing Systems for SBRT delivery Purchasing Integrated System for SBRT delivery Physics Acceptance, Commissioning, QA of these systems Clinical Implementation of Specific SBRT programs Know how it works Prove your machine works and to what degree Maintain it to work Maximise its capabilities Verify that it works on your patient.

  14. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Now the Fun part: Immobilization How accurate are these? What is accurate enough?

  15. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Image Acquisition and Registration: CT Scan (4-16-64 slices) MRI – 2D vs Volumetric Fusion Algorithms- Rigid, Deformable, etc Target and OAR delineation: Anatomy, Patterns of Failure, Consensus Based Target Prescription and OAR tolerances: Ph1 dose escalation studies, Ongoing research

  16. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Treatment Planning: Conformal Beams, Dynamic Arcs, Non-coplanar beams, Isocentric/Non-isocentric, IMRT, VMAT IGRT and correction strategies: Image acquisition- ROI, Fusion Algorithm, Tolerance Levels Motion Management: Passive- 4D CT Active- Abdominal Compression, Gating, Tracking Intra-fraction Motion (non-respiratory): Prostate and Spine motion Patient intra-fraction motion

  17. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Machine QA: Are machines delivering as they should? Process QA: Is each process robust and integrated? Patient specific QA: Are we treating the right patient with the right plan? Follow-Up: Is the patient responding as is expected? Contributing to the evidence: Reporting error and results

  18. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery THE RADIATION BOOM A Pinpoint Beam Strays Invisibly, Harming Instead of Healing By WALT BOGDANICH and KRISTINA REBELO Published: December 28, 2010 Marci Faber is nearly comatose after a treatment mistake. Evanston Hospital in Illinois Trigeminal Neuralgia Modified System Cone in Place Failure in setting backup jaws

  19. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Others: Florida: 2004-2005, 77 patients. Calibration Error (measurement of output factor) Toulouse, France: Apr 06-07, 145 patients – 31% 12 mth actuarial rate of trigeminal neuropathy in 32 acoustic neuroma Springfield, Missouri late 2004-2009

  20. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Dosimetric Impact of Motion: Spine: Precision required for dose-escalated treatment of spinal metastases and implications for image-guided radiation therapy (IGRT) Guckenberger et al Green Journal 2007 ‘To keep the dose distribution to the spinal cord within ±5% (±10%) of the prescribed dose, maximum tolerable errors of 1mm (2mm) in the transversal plane, 4mm (7mm) in superior–inferior direction and maximum rotations of 3.5° (5°) were calculated on average. The translational and rotational component of clinically observed set-up errors increased D5spine by 23±14% and 3±2% on average, respectively.’

  21. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Dosimetric Impact of Motion: Brain: Dosimetric consequences of translational and rotational errors in frame-less image-guided radiosurgery. Guckenberger et al Green Journal 2012 ‘Each 3D set-up error of 1 mm decreased target coverage and dose conformity by 6% and 10% on average, respectively, with a large inter-patient variability. Pre-treatment correction of translations only but not rotations did not affect target coverage and conformity. Post-treatment errors reduced target coverage by >5% in 14% of the patients. A 1 mm safety margin fully compensated intra-fractional patient motion.’

  22. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Multi-Stepped Process Every link in the Chain Matters Every link can be quite sophisticated Each Institution needs to design its own program according to its aims and specifications- Cannot cut and paste protocol Understand Concept, Understand Key Principles, Understand Equipment and Put them all together to achieve the intended Goal

  23. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Making Sense of the Course Program: Clinical Setup: Learn from Yamanashi, MSKCC, NCC experience and also existing setups in RCA states Multi-disciplinary Oncological Framework: Appreciate the Body of Evidence supporting SBRT and its current acceptance in the management of specific subsites Integrated Delivery System and Quality Assurance: Machine Talks to appreciate state-of-the-art delivery systems, Physics talks to show the efforts required to keep these systems operationally ready Technical Specifications unique to SBRT of each subsite: Case presentations, NCC DRO Visit, Journal Club to demonstrate specific requirements for site-specific SBRT

  24. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Can you buy a plane and go to war?

  25. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Can you buy a machine and do SBRT?

  26. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery So much coordination required just to land a plane- Unlike infantry Ops

  27. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery

  28. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery C O O R D I N A T I O N I N T E G R A T I O N

  29. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Don’t Forget Your Wingman! F16D RSAF Pilot WSO (Weapons System Officer) Radiation Oncologist Medical Physicist

  30. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery It is more than RO and MP RTTs, Nurses, Technicians etcetc Everyone in the chain can contribute Everyone in the chain can do harm

  31. The SBRT Ch∞in Introduction to the Complexities of SBRT delivery Take Home Messages: A Sexy Machine alone cannot delivery SBRT SBRT delivery is a highly complex process Successful SBRT delivery depends on the expertise of the WHOLE team Developing SBRT capabilities requires capital and commitment This RTC aims to demonstrate the breadth of a clinical SBRT program With this knowledge, National Project Teams can work in an informed manner in coordinating the setup of their respective programs

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