the technology and uses of on-treatment imaging in radiotherapy
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THE TECHNOLOGY AND USES OF ON-TREATMENT IMAGING IN RADIOTHERAPY
Venue: Stewart House, LondonCPD: 5 CREDITS
24 MARCH
2015
View the full programme and register at: www.bir.org.uk
• Room1Primers for the non-specialistsSessionorganisedbyDrDavid
Wilson,ConsultantInterventional
MSKRadiologist,OxfordUniversity
HospitalsNHSTrust
• Room2Radiation protection: current issues in molecular imaging and radiotherapySessionorganisedbyMrAndy
Rogers,HeadofRadiationPhysics,
NottinghamUniversityHospitals
NHSTrust
Save the date
• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath
Gnanasegaran,Consultant
PhysicianinNuclearMedicine,
StThomas’Hospital
• Room2Emergency radiology - advances in trauma imaging and Essentials for the radiology traineeSessionorganisedbyDrHardi
Madani,RadiologyRegistrar,Royal
FreeLondonHospitaland
DrAusamiAbbas,Cardiothoracic
RadiologyPostCCT
Day 2Day 1
BIR ANNUAL CONGRESS 20154–5 NOVEMBER
LONDON
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Day 2
Welcome and thank you for coming to ‘The technology and uses of on-treatmentimaginginradiotherapy’organisedbyTheBritishInstituteofRadiology.
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BIR Annual Congress 2015: 4–5 November, London
We are most grateful to
for supporting this conference
Please take time to visit their exhibition stands to find out moreabout the services they offer
2
Programme
09:15 Registration and refreshments
09:40 Welcome and introduction DrKeithLangmack,HeadofRadiotherapyPhysics, NottinghamUniversitiesNHSTrust
09:45 Overview of cone beam CT (CBCT) and MV portal imaging technology DrPhilEvans,ProfessorofMedicalRadiationImaging,UniversityofSurrey
10:15 Image guidance in radiotherapy: accuracy, frequency, dose, justification DrEllenDonovan,NIHRCareerDevelopmentFellow, TheRoyalMarsdenNHSFoundationTrust
10:45 Refreshments
11:15 Clinical governance in on-treatment imaging MrsÚnaFindlay,SeniorClinicalRadiotherapyOfficer,PublicHealthEngland
11:45 Image guided radiotherapy (IGRT) in clinical practice DrAngelaBaker,LeadResearchandDevelopmentRadiographer, TheClatterbridgeCancerCentre
12:15 Optimisation of cone beam CT (CBCT): balancing dose and image quality DrAndrewReilly,HeadofRadiotherapyPhysics, WesternHealthandSocialCareTrust
12:45 Lunch
13:45 Dose optimisation for soft tissue matching using a Likert scale DrKeithLangmack,HeadofRadiotherapyPhysics, NottinghamUniversitiesNHSTrust
14:15 Extraction of motion data from MOSAIQ MrWayneLomax,ProductManager,ImagingandMotionManagement, Elekta
14:30 Extraction of motion data from ARIA DrAndrewReilly,HeadofRadiotherapyPhysics, WesternHealthandSocialCareTrust
14:45 Refreshments
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15:15 Margin calculations in the context of daily online IGRT MrSamTudor,HeadofQualityControlandDosimetry, UniversityHospitalsBirminghamNHSFoundationTrust
15:45 IGRT and radiographer education MrMarkCollins,SeniorLecturerinRadiotherapyandOncology, SheffieldHallam University
16:25 Questions
16:45 Close of event
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Speaker profiles
Dr Angela BakerLead Research and Development Radiographer, The Clatterbridge Cancer Centre
AngelaBakerisLeadResearchandDevelopmentRadiographeratTheClatterbridgeCancerCentre,ChairoftheIGRTsubgroupofRTTQAandSecretaryfortheUKSABRConsortium.Herdepartmentalroleincludesresponsibilityforleadingthedevelopmentandimplementationofnewtechnologies.ThisincludesIMRT/VMAT,IGRT,4D-CT,SABRandgatingtechniques.AngelaiscurrentlyrunninganumberofdevelopmentalprotocolsatClatterbridgeusing4D-CBCTand6degreesoffreedom(DoF)couchtoimprovetreatmentaccuracy.
Mr Mark CollinsSenior Lecturer in Radiotherapy and Oncology, Sheffield Hallam University
MarkCollinsisaSeniorLectureratSheffieldHallamUniversity.Heisactivelyinvolvedintheteachinganddevelopmentofthesyllabusaroundimagingandtreatmentplanning.Hiscurrentresearchinterestsarerelatedtodecisionmakingin3D-CBCTaswellassupervisinganumberofundergraduateandpost-graduateresearchprojects.OutsideofworkheisDadtotwoyoungchildrenandakeencyclist.
Dr Keith LangmackHead of Radiotherapy Physics, Nottingham Universities NHS Trust
AftergraduationwithadoctorateinmolecularbiophysicsfromOxford,KeithjoinedtheRadiotherapyPhysicsTeamatAddenbrooke’sHospitalinCambridge.Hespentover10yearstheredevelopingspecificinterestsinbrachytherapyandimaging.AfterabriefspellinLincolnasDeputyHeadofRadiotherapyPhysicshemovedtoNottinghamin2002,wherehehasbeenthereeversince.Hiscurrentinterestsareimagingandimprovingtheefficiencyoftheradiotherapyprocess.
Dr Ellen DonovanNIHR Career Development Fellow, The Royal Marsden NHS Foundation Trust
EllenDonovanhasworkedasaClinicalPhysicistinradiotherapysince1992,firstlyatRaigmoreHospitalinInverness,andsince1995,attheRoyalMarsdenHospital,Sutton.From2002shewasPrincipalClinicalPhysicistwithresponsibilityforradiotherapytreatmentunitqualityassuranceandtechniquedevelopment.From1999to2004sheundertookapart-timePhDthatinvestigatedintensitymodulated
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radiotherapyforthetreatmentofearlystagebreastcancer.InSeptember2010shestartedanNIHR/CSOPostDoctoralFellowshipundertheHealthcareScientistsawardscheme.ThiswasfollowedbyanNIHRCareerDevelopmentFellowshipawardthatstartedinJanuary2014.
Dr Phil EvansProfessor of Medical Radiation Imaging, University of Surrey
PhilEvanshasaresearchinterestintheapplicationofphysicsandengineeringtomedicalimaging,particularlywithapplicationtoplanningradiotherapyandmaximisingitsaccuracyofdelivery.PhiljoinedTheCentreforVisionSpeechandSignalProcessing(CVSSP)inJune2012asProfessorofMedicalRadiationImagingandwithakeeninterestinapplyingimagevisionandanalysismethodstotheseimportantmedicalimagingproblems.
PhilhasaBScinPhysicsfromAstonUniversityandaDPhilinPhysicsfromTheQueen’sCollegeandtheNuclearPhysicsLaboratoryinOxford.PhilthenjoinedTheJointPhysicsDepartmentofTheInstituteofCancerResearchandRoyalMarsdenHospitalandthenledateamthereforsomeyearsworkingonimagingresearchinradiotherapybeforejoiningCVSSP.
Mrs Úna FindlaySenior Clinical Radiotherapy Officer, Public Health England
AsRadiotherapyLeadatPublicHealthEnglandÚna’sroleistoassistandsupportarangeoforganisations,includingclinicaldepartments,inaddressingradiationprotectionissuesthatmayaffectradiologicalpracticeandpatientsafety.Thisinvolvestheanalysisofradiotherapyerrorandnearmissevents(RTE)andpromulgationoflearningacrossthecommunity;theprovisionofindependenton-sitesupporttoindividualdepartments;workingwithprofessionalbodiestoprovideguidanceongoodpractice;theprovisionofsupporttoinspectoratesandDepartmentofHealth,andliaisonwithUKprofessionalbodiesandinternationalorganisations.
ÚnaisthecurrentChairofthePatientSafetyinRadiotherapySteeringGroup(PSRT),whichistaskedwithtakingthekeyrecommendationsofTowardsSaferRadiotherapyforwardandaninvitedmemberoftheRadiotherapyBoard.
Mr Wayne LomaxProduct Manager, Imaging and Motion Management, Elekta
WayneLomaxistheProductManagerforImagingandMotionManagementforELEKTA’ssoftwareproductsandbringswithhimanextensivewealthofclinical
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experience.WaynehasbeenatELEKTAforover5yearswherehestartedasaClinicalProductSpecialistgivingdirectclinicalinputtotheR&Dprojectsforimaging.HethenprogressedtobecometheImagingProductSpecialistandProductManagerwithinELEKTAdrivingforwardcommercialproductreleasessuchasXVI,iView,MOSAIQandjointdevelopmentofaCTonRailssystemwithToshibaMedicalinJapan.HavingtrainedasaRadiationTherapistinoneoftheUK’sandEurope’sleadingcentresandworkedatnumerouscentreswithintheUK,Waynehasquicklyestablishedhimselfwithinhisprofession.Hisstrongtechnicalability,forwardthinkingandpassionforbringingvaluetoELEKTA’susers,keepsELEKTAattheleadingedgeofimageguidedradiotherapy,bothindevelopmentandpractice.
Dr Andrew ReillyHead of Radiotherapy Physics, Western Health and Social Care Trust
AndrewReillyisHeadofRadiotherapyPhysicsatAltnagelvinHospital,Londonderry.Throughouthiscareerhehassupportedtheclinicaluseanddevelopmentofradiotherapyimagingtechnologiesandworkedtowardsimprovedsystemsintegration.Hehasaparticularinterestinbridgingthegapbetweendifferentimagingdisciplinesandoptimisingimagingacrosstheradiotherapyprocess.HeisfounderoftheIQWorksproject,leadstheRadiotherapyImagingUserGroupandprovidedphysicssupportunderthenationalNRIGmentoringprogrammeforIGRTimplementation.AndrewservedasChairmanoftheBIRRadiationPhysicsandDosimetryCommitteeuntil2009,wasamemberofBIRCouncilfrom2010to2013,representstheBIRontheDHMedicalPhysicsExpertworkinggroupandcurrentlychairstheBIRInformaticsandClinicalIntelligenceSpecialInterestGroup(SIG).
Mr Sam TudorHead of Quality Control and Dosimetry, University Hospitals Birmingham NHS Foundation Trust
SamTudorisHeadofQCandDosimetryatUniversityHospitalsBirmingham.Hehasinterestsintheuseofradiobiologicalmodellingtoinformtheeffectofgeometricuncertaintiesandimagingstrategies,aswellasthedosimetryofcomplex,smallorunflattenedbeams.Heiscurrentlystudyingforapart-timePhDintheeffectofgeometricuncertaintiesontreatmentsuccess.
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Abstracts
Overview of cone beam CT (CBCT) and MV portal imaging technologyDr Phil Evans
Modernradiotherapyusesimageguidancetotargetthetreatmentaccuratelytothetargetavoidingnormaltissueasefficientlyaspossible.Thispresentationwillcommentonsomeofthecommonlyusedtechniquesforimaginginimageguidedradiotherapy(IGRT).
Severaltechniquesexistandthereiscurrentlynoclearevidencethatasingleoneisbesttouseinallcircumstances.ThemethodstobediscussedincludekilovoltageconebeamCT(ElektaandVarian),megavoltageCT(bothconebeamandslicefromSiemensandTomotherapy),planarimaging(bothkVradiographyandMVportalimaging)andnewerimplementationsoftheseapproachesincludingthecyberknifeandbrainlabmarkerbasedtrackingsystemsandtheverogimballedheadsystem.Competingtechnologiesincludeultrasoundforsofttissuevisualisation,thecalypso,implantedelectromagnetictransponderapproachandtheMRtreatmentunit.
Thecharacteristicsofthesekeysystemswillbepresentedandcomparedwithadiscussionoftheprosandconsofthevariousapproaches.Inadditionthecombinationofmethodswillbediscussed.Thiswillinclude,astheprimaryexample,thecombinationofkVX-raywithopticalsystemsfortrackingmotion.ThedosesdeliveredbytheX-raybasedsystemswillbediscussed,bothintermsoftheoreticalconsiderationsanddosedemonstratedbyavailablesystems.
Learningoutcomes:• Understandingofthecurrentstateoftheartforradiotherapyimagingtechnology• Understandingoftheprosandconsoftheavailableradiotherapyimagingsystems• Understandingofdoseconsiderationsinradiotherapyimaging• Understandingofsomeoftheoutstandingchallengesinradiotherapyimaging• Understandingofthenon-ionisingradiationapproachestoradiotherapyimaging
Image guidance in radiotherapy: accuracy, frequency, dose, justificationDr Ellen Donovan
Background:Imageguidanceisacrucialpartoftheradiotherapychainandisintegratedwithinhighqualityradiotherapytreatment.Itistheroleofimageguidanceinensuringhighlyaccurateandpreciseradiotherapytreatmentthatprovidesitsjustification.ThispresentationisbasedonthedefinitiongivenintheNationalRadiotherapyImplementationGroupReport2012[1]thatstates“ImageguidedRadiotherapy(IGRT)isanyimagingatpre-treatmentordelivery…thatimprovesorverifiestheaccuracyofradiotherapy”.
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Imageguidedradiotherapyprotocols:AppropriatemodificationsshouldbemadetothestandardimagingprotocolssetuponIGRTequipmentwhenitisinstalled.Theseshouldfocusonprovidingtheimagequalitynecessarytoachieveanaccurateradiotherapydelivery.Appropriateuseofverificationprotocolsisgoodpractice,andcanreducetheimagingdosecomponentoftotalorgandose,ifthisisofconcern.
Impactofimageguidance:Twostudies(Hawkinsetal[2]Donovanetal[3])areusedtodemonstrateaquantificationofthebenefitofIGRT.
Educationandlearningoutcomes:• Appreciationoftheimportantofimageguidanceinradiotherapyandits
justificationasanintegralcomponentofaradiotherapyepisode• Understandingoftherelativecontributionofradiotherapyandimagingdose
tototalorgandose• Useofstandardverificationprotocolstobalancetheaccuracy,frequencyand
doseofon-treatmentimaging
Keyreferences:1. NationalRadiotherapyImplementationGroup.Image Guided Radiotherapy
(IGRT) Guidance for implementation and use; 20122. Hawkins,MA,Brooks,C,Hansen,VN,Aitken,A,Tait,DM.Conebeam
computedtomography-derivedadaptiveradiotherapyforradicaltreatmentofesophagealcancer.Int J Radiat Oncol Biol Phys 2010;77:378–383.
3. DonovanEM,BrooksC,MitchellRA,MukeshM,ColesCE,EvansPMetal.TheEffectofImageGuidanceonDoseDistributionsinBreastBoostRadiotherapy.Clin. Oncol2014;26(11);671–676
Clinical governance in on-treatment imagingMrs Úna Findlay
Theclinicaluseofimageguidedradiotherapyhasincreasedrapidlyinthelastfewyears.PortalimagingisbeingsupersededbyconebeamCT(CBCT)inanumberofsites.Howeverthereareon-goingdebatesaroundimagingfrequency,dosemeasurementandmargincalculations.Theimportanceofsafelymanagingtheassociateddoseburdenforthepatientshouldalsobecarefullyconsidered.
ClinicalgovernancehasbeendefinedasaframeworkthroughwhichNHSorganisationsareaccountableforcontinuallyimprovingthequalityoftheirservicesandsafeguardinghighstandardsofcarebycreatinganenvironmentinwhichexcellenceinclinicalcarewillflourish.TheIonisingRadiation(MedicalExposure)Regulations(IR(ME)R)islegislationintendedtoprotectthepatientfromthehazardsassociatedwithionisingradiationintheUK.
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ThispresentationwillreviewtheroleofclinicalgovernanceandtheimplicationsoftheIR(ME)Rinconcomitantimagingprocessesinradiotherapywithafocusonthejustificationandoptimisationoftheseexposures.
Keyreference:ScallyGandDonaldsonLJ.ClinicalgovernanceandthedriveforqualityimprovementinthenewNHSinEngland.British Medical Journal1998;317 (7150),61-65.
Image guided radiotherapy (IGRT) in clinical practiceDr Angela Baker
Followingthepublicationofnationalguidelines,imageguidedradiotherapyhasbeenwidelyimplementedacrosstheUKandIGRTisbeingusedthroughoutthetreatmentprocess.ThecurrentstatusofIGRTintheUKwillbediscussedandclinicalcasespresentedwherethetechnologyisbeingutilisedwithconsiderationofsitespecific,individualisedprotocols.Theroleofclinicaltrialsintheevaluationandimplementationofimageguidedradiotherapywillbedescribedtogetherwithtrainingimplicationsofthetechnology.Theadventofimageguidancetechniquesprovidesopportunitiesandchallengeswithinthedepartmentbutalsomanyopportunitiesforrolechanges.Thepresentationwillfinishdiscussingtheroleofadaptiveradiotherapyandfuturetechnologies.
Educationalaims:• ToconsideradvancedIGRTandadaptiveprocessesandtheirimpacton
departmentalroles
Learningoutcomes:• Todemonstratetheabilitytocriticallyevaluatesitespecificimageguided
techniques• Todemonstrateknowledgeofthetypesofadaptivetechniquescurrently
available• Toconsidertheimpactofchangingroleswithinthemulti-professionalteam
Optimisation of cone beam CT (CBCT): balancing dose and image qualityDr Andrew Reilly
CBCTatthepointoftreatmentdeliveryisnowwidelyaccessibleanditsadoptionhasincreaseddramaticallysincethepublicationoftheNRIGreportonimplementingIGRTanditssupportingmentoringprogramme.AlthoughCBCTundoubtedlymakesmoreinformationavailableaboutpatientsetupthaneverbefore,itisalsothetreatmentimagingmodalitywiththehighestpatientdose
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burden.CaremustthereforebeexercisedwhenusingCBCTfordailyimaging.Optimisationinvolvesbalancingcompetingfactors:ensuringimagesacquiredaresuitablefortheclinicaltaskwhilstminimisingtheburdentothepatient.
Methodsforobjectivelyevaluatingclinicalimagequalityareexplored,includinglinking“physics”measurementsonphantomsbacktotheclinicaltask.Theimportanceofthehumanobserverisemphasised.
Thereissignificantdebatewithintheradiotherapycommunityregardingthemeasurement,quantificationandmanagementofconcomitantdosefromimaging.Apragmaticapproachtothisissuggestedbybuildingonexperiencefromclinicaltrialsandharnessingdataautomaticallycollectedthroughroutineworkflowactivities.Thepotentialroleofimagingdosereferencelevelsisconsideredandthedevelopmentofpeersupportnetworksissuggested,encouragingcancercentreswithsimilarequipmentandcase-loadstoshareprotocolsandexperiences.
Balancingtherelativeimportanceofthevarioustasksacrosstheradiotherapyprocessisanimportantelementofoptimisationinradiotherapyimaging.OpportunitiesfordevelopingrobustCBCToptimisationstrategiesthroughclosemulti-disciplinaryworkingandbuildingrelationshipswithpeersindiagnosticimagingareconsidered.
Avarietyofreal-worldclinicalexamplesisusedtoillustratethechallengesandopportunitiesdiscussedthroughoutthepresentation.
Dose optimisation for soft tissue matching using a Likert scaleDr Keith Langmack
Thepresentationwillstartwithadiscussionofclinicalimagequality.Imagequalityisacomplexmeasureasithasanumberofdifferentaspectstoit.Itispossibletoidentifyfourdimensionsofimagequality:physical(e.g.DQE);psycho-physical(responsetovisualstimuli);observerperformance;anddiagnosticperformance.Inverificationimagingwearenotcarryingoutadiagnosis,however,wecouldreplacethiswith“matchingperformance”.Forthisstudywedefinedimagequalityinrelationtothespecificmatchingtask(softtissuematching)suchthattheimagecarriedenoughinformationtoallowadecision(matching)tobemadewithanacceptabledegreeofcertainty.
Theremainderofthepresentationwilldescribethestudy.TheNottinghamVAMTprostateprotocolrequiresdailyCBCTimagingpriortotreatment.Attheintroductionofthistypeofimagingweusedthemanufacturersuppliedpre-sets.Thesewerefoundtogiveadequateimagequalityforsofttissuematching.Oncewehadbecomeconfidentwiththisprocedure,weinvestigatediftheimagingdosecouldbereducedwhistmaintainingadequateimagequality.Phantom
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studieswiththecatphanandCRISvisiblehumanpelvisphantomindicatedthatitmightbepossibletoreducetheimagingdosebyasmuchas33%.However,patientsarefarmorevariablethanphantoms,sowedecidedtocarryoutaserviceimprovementstudywithacohortofaround20patients.
Forthisstudyweset-upthreedoselevelpre-setswithinourXVI/Mosaiqsystem—fulldose,80%doseand63%dose.TomeasureimagequalitywesetupafourpointLikertscale(excellent,noartefacts;good,fewartefacts;poor,justabletomatch;unsatisfactory,notabletomatch).Thiswasdiscussedwiththeradiographerson-setwhowouldbedoingthematchingsothattheyunderstoodwhatwasrequired.Thestudyprotocolrequiredthetreatmentradiographerstoassessandrecordimagequalityonadailybasis.Forthefirst12fractionsthe“100%dose”pre-setwasused.Forthenext12fractionsthe“80%dose”protocolwasusedwiththeprovisothatiftheimagequalityprovedunsatisfactorythentheywereabletoreverttothepreviousdoselevel.Forthefinalfractionsthe“63%dose”protocolwasused,againwithaboveproviso.
ThedatawasanalysedwiththeFreidmantestfollowedbytheWilcoxonsignedranktestwithBonferroniadjustmentforrepletion.Thisanalysiswillbeexplainedinthepresentation.Theresultsofthestudyshowedthatwecouldusethe“80%dose”protocolforallpatients,withthe“63%dose”protocolforpatientswithalateralseparationlessthan35cm.Thishasnowbeenclinicallyimplementedwithnoreportedissues.WeaimtorepeatthisstudyforotherbodysiteswhereweroutinelyuseCBCTimaging.
Extraction of motion data from MOSAIQMr Wayne Lomax
ELEKTA’sMOSAIQOncologyInformationSystemhasawealthofdataandknowledgerelatingtonotonlythepatientanditscarepathbutalsoyourradiotherapyandoncologydepartments.OnesuchdataMOSAIQisabletorecordfromnumerousvendorsviaspatialregistrationobjects,registeringimageswithinMOSAIQorgeneralmanualrecordingisoffsetdatafromdailyIGRT.
DuringthissessionweintendtocoverhowtoextractdailyIGRToffsetdataforapatientbygeneralreportingincludedinMOSAIQforuseoutsideoftheMOSAIQenvironment.WewillalsocoverwhereandhowyoucangethelporlearnhowtocreatecustommorecomplexreportsfromyourMOSAIQdata.DuringthesessionwewillalsotouchonsomeotherareaswithintheELEKTAIGRTproductswheredatacanbeextractedrelatingto4Dmotiondata.ThesessionwillalsogiveaglimpseintothefuturevisionofELEKTAsoftwareandinformationguidedcancercare.
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Extraction of motion data from ARIADr Andrew Reilly
ARIAasanoncologymanagementsystem(OMS)isunderpinnedbyadatabasethattrackseveryaspectofthetreatmentdeliveryprocess.Thisincludessetupverificationimaging,detailsoftheimagematchingprocess,respiratorymotionwaveformsandcouchpositionsduringimagingandtreatment.Additionalinformationsuchasthetimingsofdifferenteventsandtheoperatortakingresponsibilityforthetreatmentarealsorecorded.
ThispresentationdescribestheextractionofdatafromARIAtocharacteriseinter-andintra-fractionmotion.Thedatacanbeutilisedtocalculaterandomandsystematicsetuperrors,whichinturnmayfeedintomargincalculationsusingthealgorithmsintheRCR“OnTarget”reportorotherpatientsetupmodelspublishedintheliterature.Evaluatingrespiratorywaveforminformationovertimeenableschangesinbreathingmotiontobeidentifiedandfacilitatesinvestigationofpotentialsynchronisationissuesbetweenthemovementofinternalanatomyandthatoftheexternalsurrogate.
Anumberofdataextractionmethodsareconsidered,allsuitedtodifferentoperationalconditionsyetallyieldingthesameoutputdata.Theseincludeusingtoolsbuilt-intotheARIAuserinterface,advancedARIAreporting,ARIAscriptingandARIAanalytics.
AlthoughtheNRIGreportonimplementingIGRTencouragestheroutinemonitoringandanalysisofsetuperrorsthishasnotyetbeenfullyrealisednationwide.Apotentialcommunityinitiativeissuggestedasameansofachievingthis.
Margin calculations in the context of daily online IGRTMr Sam Tudor
IntheabsenceofIGRT,andtosomeextentwhereIGRTtechniquesareperformedlessfrequentyandoff-line,thereexistsignificantsourcesoftranslationalgeometricinaccuracy,includingsetuperroranddailyinternalmotionofthetargetwithinthepatient.Thesesourcesoferrorare,however,typicallyeasytomeasureandincorporateintoaCTV-PTVmarginformulaesuchasthevanHerkformula(BIR2003[1],vanHerketal.[2]).Theincorporationofothercomponents,includingrotationalerror,intrafractionalmotionanddelineationerror,intothevanHerkmethodologyposessomeproblems,butwhenthesecomponentsweredeterminedtoberelativelysmall,theexactmethodoftheirconsiderationhadlittleimpactonthecalculationofthetotalCTV-PTVmargin.
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However,inthecontextofdaily,onlineIGRT,thelargerandmoreeasilyconsideredcomponentsofuncertaintyarethefirsttodisappear.LessscrutablecomponentssuchasrotationalerrorandintrafractionalmotionarelesslikelytobecorrectedbytheIGRTsystem,andtheyarejoinedbyanadditionalcomponentofregistrationerrorthatcanbesimilarlydifficulttoconsiderhowtomeasureandacton.
ThispresentationdiscussessomeofthefeaturesofresidualcomponentsofuncertaintythattypicallyremainaftertheintroductionofdailyonlineIGRT,andpresentstechniquestoincorporatesomeoftheseintoconventionalmarginformulae.
AbriefdiscussionofmarginformulaebasedonradiobiologicalmodellingwillfollowtogetherwithconsiderationoftheirworthinlightofthelimitedpublishedclinicalevidenceofmarginreductionwithIGRT.
Keyreferences:1. BIR.PreparedbyaWorkingPartyoftheBritishInstituteofRadiology.
Geometricuncertaintiesinradiotherapy:definingtheplanningtargetvolume.London,UK:2003.(ISBN0-905749-53-7).
2. VanHerkM,RemeijerP,RaschCandLebesqueJ.V.Theprobabilityofcorrecttargetdosage:dose-populationhistogramsforderivingtreatmentmarginsinradiotherapy. Int. J. Radiat. Biol. Phys.2000;47 (4),1121-1135.
IGRT and radiographer educationMr Mark Collins
Theroutineimplementationof3Dimagingduringtreatmentverificationhasbeenoneofthelargestchangesinradiotherapypracticeinthelast10years.Thespeedatwhichthistechnologyhasbeenimplementedhasraisedanumberofissuesfortheradiotherapycommunityandtheprofessionalsinvolvedintheeducationoftheworkforce.
HigherEducationInstitutions(HEIs)playalargeroleinthetrainingoftherapyradiographers.TheultimategoaloftheHEIistotraingraduatesthatarefitforpurposeinthemodernradiotherapydepartment.ItisessentialthatHEI’sdeveloptheircurriculumandadaptmethodsofdeliverytokeeppacewiththeimplementationofthistechnology.
Thereareanumberofquestionsandchallengesthatmustbeovercomebeforethiscanhappen.Therapyradiographerstypicallyspendaround50%oftheirtraininginaclinicaldepartmentand50%inacademia.AtSheffieldHallamUniversity(SHU),studentsarebasedatonesiteforallclinicalpracticewiththeexceptionofa3weekelectiveplacement.Thisallowsstudentstobecomefamiliar
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withtheprotocolsandpracticesatthissite,aswellasgivingthemtheskillsandexperiencetheyneedtoworkinthewiderradiotherapycommunity.Asaresultofthismethod,studentsareexposedtoworkingpracticesincludingradiotherapytreatmenttechniquesandIGRTpracticeinoneplacementenvironment.
AnumberofstudieshavedemonstratedthatIGRTpracticevariessignificantlyacrosstheUK.ThesestudiesreflecttheexperiencesofstudentsatSHU,withstudentsreportingverymixedexperiencesofIGRTtrainingwhilstonplacement.Aswithotheraspectsoftheundergraduatesyllabus,IGRTtrainingshouldideallybedeliveredinpartnershipwiththeHEIandclinicaldepartmentsbothtakinganactiverole.Attimes,theimplementationofthiscanbeproblematicduetoanumberofconstraints.Theseincludetheavailabilityofthetechnologyinsomeclinicalsitesaswellasstaffingresourcesandvaryinginter-departmentalstaffingstructuresforimagereview.
ThequestionofwhatlevelofIGRTskillsandcompetencesarerequiredofnewgraduatesremainsunanswered,andasaprofessionweneedtoworktowardsdefiningcommoncompetencies.Overthelast2years,SHUhassignificantlydevelopeditsIGRTteachingsyllabus.Inthesecondandthirdyearsoftheirtraining,studentscarryoutanumberofpracticalsessionsusingcasestudiesonVarianAria.Thesehavebeenwellreceivedbystudents,butacommonthemeofthefeedbackisthatstudentswouldlikemoretimeforthesesessions.
SHUisworkingcloselywithitslocalclinicaldepartmentstotrainitsgraduatestohavetheskillsandcompetenciestheyneed.TheywillbeconductinganationalsurveyinlatespringtogainawiderperspectiveonundergraduateIGRTtraining.
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FORTHCOMING EVENTS
MANAGEMENT AND RADIOLOGY—A GUIDE TO CURRENT AND FUTURE MANAGEMENT ISSUES IN RADIOLOGY
1 MAY 2015LONDON
AN EVENING WITH PROFESSOR LÁSZLÓ TABÁR:A NEW ERA IN THE DIAGNOSIS AND TREATMENT OF BREAST CANCER
11 MAY 2015LONDON
THORACIC IMAGING15 MAY 2015CAMBRIDGE
IMAGING IN DEMENTIA18 MAY 2015
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EMERGENCY OUT OF HOURS RADIOLOGY20 MAY 2015
GLASGOW
NEURORADIOLOGY UPDATE AND REFRESHER COURSE18–19 JUNE 2015
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WESSEX BRANCH SUMMER EVENT19 JUNE 2015CHICHESTER
FUNCTIONAL IMAGING IN RADIOTHERAPY10 JULY 2015
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