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© 2015 Vision RT Ltd
MORE THAN JUST MOTION MANAGEMENT Tim Nicholson - Vision RT Ltd 4th August 2013
Cedars-Sinai Medical Center
Presenter
Title, Vision RT Ltd MM-DD-YY | Venue
Presenter
Title, Vision RT Ltd MM-DD-YY | Venue
3D PATIENT TRACKING FOR RADIATION THERAPY
© 2015 Vision RT Ltd
VISION RT: COMPANY VISION
Setting a new standard of care in motion
management during radiation therapy
Non-invasive, non-ionizing, non-contact, real-time
Reduce treatment time
Improve patient comfort
Increase patient safety
Complex treatments -> routine
Standard of care -> Every Linac, every patient, every fraction
© 2015 Vision RT Ltd
USER MEETING 2015
Highlights from Meeting:
May 14-15 2015
Denver, CO
EVERY PATIENT, EVERY FRACTION, EVERY TREATMENT
© 2015 Vision RT Ltd
PRODUCT OFFERRING
AlignRT®
Patient setup and surveillance
GateCT®, GateRT®
4D CT and respiratory gating
AlignRT® Plus:
Frameless SRS Module
All FDA Cleared Products
© 2015 Vision RT Ltd
USER COMMUNITY INCLUDING
Almost 400 systems installed worldwide (backlog: >125) installed in more than 30 NCI
designated cancer centers in the US:
Cleveland Clinic
Dana Farber Cancer Institute
Dartmouth-Hitchcock Medical Center, NH
Emory University
Huntsman Cancer Hospital
Massachusetts General Hospital
Mayo Clinic, Rochester
Memorial Sloan Kettering Cancer Center
MD Anderson Cancer Center: Houston, Orlando
Ohio State University
Procure: Indiana (Training Center); Oklahoma City
21st Century Oncology, US Oncology
University of California: San Diego, Davis, San Francisco
University of Florida: Gainesville, Jacksonville
University of Maryland
University of North Carolina
University of Iowa
University of Pennsylvania
UT Southwestern
© 2015 Vision RT Ltd
SYSTEM OVERVIEW
Key functions of Vision RT technology
Patient setup
Intra-fraction surveillance
4D treatment planning and delivery
© 2015 Vision RT Ltd
REAL TIME 3D SURFACE IMAGING: CORE PRINCIPLES
Camera Calibration 3D Triangulation
AlignRT camera unit
© 2015 Vision RT Ltd CONFIDENTIAL
REAL TIME 3D SURFACE IMAGING: CORE PRINCIPLES
Stereo matching algorithm
Match all possible corresponding points
Produce 3D triangulated mesh
Other approaches:
- Structured light
- Laser stripe
© 2015 Vision RT Ltd
Christoph Bert, Katherine G. Metheany, Karen Doppke, George
T. Y. Chen. A phantom evaluation of a stereo-vision surface
imaging system for radiotherapy patient setup. Med. Phys.
32(9), pp. 2753-2762, Sep 2005.
P.J. Schöffel, W. Harms, G. Sroka-Perez, W. Schlegel and C.P.
Karger. Accuracy of a commercial optical 3D surface imaging
system for realignment of patients for radiotherapy of the
thorax. Physics in Medicine and Biology; 52: 3949-3963; June
2007.
Results comparing AlignRT outputs with those measured from strain gauges
STUDIES: SYSTEM ACCURACY
© 2015 Vision RT Ltd
BREAST APPLICATIONS
This customer quote reports on the clinical use and performance of Vision RT products by independent users. This has not been validated by Vision RT and thus is not
endorsed by Vision RT. Users of Vision RT’s products should develop and validate their own workflows consistent with clinical practice within their facility.
We’ve had 53 out of 54 patients where we have not had to repeat their weekly X-Ray
images, so 98.1% of our patient’s weekly X-Ray images have been approved without
need to repeat. That is a significant finding for us – it’s showing us that we’re getting a
dose reduction because we’re not having to repeat X-Ray images on these patients, and
it’s also showing us how reliable the AlignRT system really is in patient positioning.
Heather Warmouth BS RT(T), Radiation Therapist, Fletcher Allen Health Care
General breast
Prone breast
DIBH (left breast): New data
from SPECT study; User
Meeting, ASTRO
© 2015 Vision RT Ltd
D.P. Gierga, M. Riboldi, J.C. Turcotte, G.C. Sharp, S.B. Jiang, A.G. Taghian, G.T.Y. Chen. Comparison of Target
Registration Errors for Multiple Image-Guided Techniques in Accelerated Partial Breast Irradiation. International
Journal of Radiation Oncology Biology Physics. 70(4); p. 1239-1246; March 2008.
A.J. Chang, H. Zhao, K. Moore et al. Video surface image guidance for external beam partial breast irradiation.
Practical Radiation Oncology; August 2011
D. Gierga, J. Turcotte, G. Sharp et al. A Voluntary Breath-Hold Treatment Technique for the Left Breast With
Unfavorable Cardiac Anatomy Using Surface Imaging. International Journal of Radiation Oncology Biology Physics.
July 2012.
X. Tang PhD, T Zagar, E. Bair et al. Clinical experience with 3-dimensional surface matching-based deep inspiration
breath hold for left-sided breast cancer radiation therapy. Practical Radiation Oncology; p. 151-158; May-June 2014
New SPECT study (UNC): Initial results presented at User Meeting; Additional data to be presented at ASTRO
BREAST APPLICATIONS: PUBLISHED STUDIES
© 2015 Vision RT Ltd
CLINICAL APPLICATIONS: BREAST
Vision RT is a very good way to
support the breath hold technique to
reduce heart exposure to our
patients with left sided breast
cancer Larry Marks MD
Chairman Radiation Oncology,
UNC, Chapel Hill
I think this is a very crucial part of
my breast cancer care for patients
with left sided breast cancer
Ellen Jones MD PhD
Vice Chair Radiation Oncology,
UNC, Chapel Hill
DIBH Patient Treatment
© 2015 Vision RT Ltd
DEFINE REFERENCE TREAT
CLINICAL APPLICATIONS: BREAST
Acquire DIBH
CT data
SETUP PATIENT
Set up to
breast during
DIBH using
RTDS
Define ROI
around
breast
Track DIBH and
enable when in
tolerance
DEEP INSPIRATION BREATH-HOLD (DIBH)
© 2015 Vision RT Ltd
Background Traditionally, SRS has been niche, invasive, expensive and time-consuming
GammaKnife: Lars Leksell (1949) → Elekta
Cyberknife (Accuray)
Novalis (BrainLAB)
Linac + biteblock
FRAMELESS SRS
© 2015 Vision RT Ltd CONFIDENTIAL
Why Frameless SRS?
Patient comfort: Open mask
Safety: Continuous monitoring of any motion under
the mask in real time
Accuracy: Sub millimetric; Correct for couch walk
Efficiency: Frameless SRS on conventional Linac
→ 20 minute treatment time
FRAMELESS SRS
© 2015 Vision RT Ltd
SRS Calibration
Imaging of internal spheres (MV) and external surface (AlignRT): Software calculates for isocenter
mismatches
Allows high accuracy tracking of patient for all couch angles
Verify kV and lasers
VRT, MV, kV isocenter(s) coincident
FRAMELESS SRS
© 2015 Vision RT Ltd
3Degree Head Adjuster
FRAMELESS SRS
Accurate and efficient
Allows the precise corrections of pitch, yaw and roll rotations to the head
Adjustments can be applied to within a tenth of a degree
Saves time (~10 mins per treatment - UCSD) -> increases patient throughput
Bolts on with quick release clamps to standard couch tops
© 2015 Vision RT Ltd
SETUP PATIENT DEFINE
REFERENCE TREAT
CLINICAL WORKFLOW
Acquire CT
scan and
define ROI
Track patient: Beam hold
if motion detected
FRAMELESS SRS
Acquire
CBCT data
& reference
surface
Plan for
couch
rotations
UCSD workflow
Preliminary
setup: RTDs
© 2015 Vision RT Ltd
FRAMELESS SRS: CLINICAL STUDIES
Nhat-Long L. Pham, Pranav V. Reddy, James D. Murphy, Parag Sanghvi, Jona A.
Hattangadi-Gluth, Grace Gwe-Ya Kim, Laura Cervino, Todd Pawlicki, Kevin T. Murpy,
Frameless, real-time, surface imaging-guided radiosurgery: update on clinical
outcomes for brain metastases, Translational Cancer Research, 3, 4, 351-357,
August, 2014
163 patients: outcomes study, 6.7 months follow up; equivalent to frame based.
Anthony J. Paravati, Ryan Manger, Jasmine D. Nguyen, Sofia Olivares, Gwe-Ya Kim,
Kevin T. Murphy, Initial clinical experience with surface image guided (SIG)
radiosurgery for trigeminal neuralgia, Translational Cancer Research, 3, 4, 333-337,
August, 2014
First 7 TN patients at UCSD
H. Pan, L. Cerviño, T. Pawlicki et al., Frameless, Real-Time, Surface Imaging-Guided
Radiosurgery: Clinical Outcomes for Brain Metastases, Neurosurgery, 71(4), 844-
852, October, 2012
44 patients: outcomes study, 6 months follow up; equivalent to frame based
© 2015 Vision RT Ltd
No invasive frame is required
CLINICAL APPLICATIONS: SBRT
Patient exposed; made as comfortable as possible
CDR CIVCO
© 2015 Vision RT Ltd
SETUP PATIENT
CLINICAL WORKFLOW
CLINICAL APPLICATIONS: SBRT
Preliminary
setup: RTDs
Acquire
AlignRT
reference
DEFINE
REFERENCE
Acquire CT
scan and
define ROI
TREAT
Track patient: Beam hold if motion
detected
Acquire CBCT
data: Apply shifts
to patient
© 2015 Vision RT Ltd
SARCOMA EXTREMITIES
Play video
D. Gierga, J. Turcotte, L. Tong et al. Analysis of setup uncertainties for extremity sarcoma
patients using surface imaging. Practical Radiation Oncology. 2013.
“Intrafraction motion is small. Interfraction motion can exceed typical PTV margins
and daily imaging should be utilized to reduce setup variations. Surface imaging may
reduce setup errors and is a feasible technique for daily image guidance.”
© 2015 Vision RT Ltd
CLINICAL APPLICATIONS: RESPIRATORY GATING
© 2015 Vision RT Ltd
4D CT
Position
patient and
acquire scout
CT scan
: RESPIRATORY GATING
Track
patient’s
breathing until
it is regular
Measure phase
of full breathing
cycle for 4D CT
Select tracking
points and
start 4D scan
Review data;
export to 4D
workstation;
reconstruct
4DCT
4D PLANNING
4D treatment
planning: determine
need for gating
GATED TREATMENT
Phase based
respiratory gating
Displacement
based gating
Play video
© 2015 Vision RT Ltd
EVERY PATIENT, EVERY FRACTION, EVERY TREATMENT
Within a few months of using AlignRT, we
realized that we could no longer justify treating
our patients without it. Consequently, we have
deployed additional systems for our satellite
facilities to be used for all treatments, including
DIBH, SBRT and SRS
Nancy Wiggers MD, Northside Hospital, GA
© 2015 Vision RT Ltd
DEFINING THE STANDARD OF CARE IN MOTION MANAGEMENT