1. IMPLEMENTATION OF A
TOMOTHERAPY BASED IMAGE-
GUIDED IMRT PROGRAM THROUGH
A FULL SCOPE OF RADIATION
THERAPY PRACTICE MODEL
The Ottawa Hospital Regional Cancer Centre
Ottawa, Ontario
April 2008

2. The Ottawa Hospital Cancer
Centre
• Treats approximately 4000 patients annually
• 9 conventional linacs (6 Siemens, 3 Elekta Synergy)
• 2 TomoTherapy Hi-ART

3. Implementation of 1st Unit
•Installation = 8 days
•Acceptance and commissioning = 2 weeks
•Therapist training = 2 weeks
•1 week without patients
•1 week with patients
•1st patient = 12 September 2005
•Initially 5-6 patients/day
•2nd Tomo Unit installed Oct/07
•Currently treat 18-20 patients in 8hr day
•25 min bookings

4. Patients Treated from Sept 05- Current
Site Number of Patients
H&N 128
PELVIS 83
SPINE 22
CNS 24
LUNG 23
ABDOMEN 7
BREAST 23
TOTAL 311

5. Treatment and Planning
• Started with three therapist planning and delivering
treatments
– Selected therapists had no previous treatment planning
experience
– Training was excellent
– Visited three other Tomo sites to gain knowledge and
experience
– Planning is an on-going learning experience

6. Average Planning Time (min)
Task 1st 3m After 9m
70 40**
Rad Onc. Targets
86 23
Work @ Planning Station
22 6
ROIs
82 73
Beamlets
180 120
Optimization
33 6
Time with Onc
62 60
Physics QA
Total 535 328
Currently, average time = 5.5hrs
**Some targeting takes
longer than 40 mins

7. Planning
• Therapists like treatment/planning model because:
– More knowledgeable when registering MVCT
– Therapists are able to adjust treatment plans to
reduce/limit some observed side effects
– No ‘hand off’ or transfer of information
– Able to contribute to prospective protocols
• We now have 7 therapists for 2 units on ‘Team Tomo’

8. Cord Not Aligned – Need for PRV
Inf. End of
cord not
perfectly
Sup. aligned.
End ok.
Yellow = PRV
cord – good thing
PRV= Planning at Risk Volume (ICRU recommendation)

9. Tomo Group Meetings
• Radiation Oncologists, Therapists and Physics meet weekly to
determine:
– Who is eligible for treatment (protocols)
– Who can benefit most from IMRT treatment (nonprotocol)
• Potential CTVs are reviewed to determine:
– Need for bolus and its placement
– Immobilization device requirements
• Review treatment plans of patients on treatment

10. Therapist Perspective
• Therapists feel they are;
– Using full-scope-of-practice
– Involved at all levels of decision making
• Patient suitability
• Targeting
• Planning
• Treatment
• Education
• Research

11. Additional Responsibilities
• Protocol development
• Image-guided treatment delivery
• Development of policy and procedures
• Research
– Testing of new software
– Adaptive planning
– Publications

12. RTOG 0521 66/60/56 in 33
Added sparing
structures used
to reduce
toxicities

13. Unknown Primary 66/60/56 in 33
Targets are
homogeneous

14. OTT 06-04
In-house Breast + Nodes(IMC) Protocol

15. OTT 06-04
In-house Breast + Nodes(IMC) Protocol
V20= 6.8%
V5 = 36%

16. T2N1MO Squamous cell Anus
Three PTV’s 60/55/48 in 30 (+chemo)
Rad Onc initially wanted
to treat patient in three
phases. Tomo team was
able to created plan
using alternate
fractionation.

17. Whole Brain 3000/10 +
Simultaneous Boost to 3 iso
4500/10 in 1plan (25 min)
**London Protocol

18. CNS – Avoidance Structure in
Mid Brain
Therapist created
this distribution.
Pt is treated
supine and has
reduced toxicities

19. StatRT = Scan/Plan/Treat = 40 min
Scan
• Place patient on the couch
• Scan selected region
• Acquire MVCT image set
Plan
• Perform 3D contouring at the Operator Station
• Set prescription
• Optimize the treatment fraction
• Evaluate using isodose distribution and dose volume histograms
(DVHs)
Treat
• Helical IMRT delivery
• Conformal 3D dose distributions
• Simple to complex cases

20. Clinical Pilot
• 25 palliative patients
• Fractionated and single treatments
– Spine
– Abdo
– Lung
– Pelvis

21. StatRT - Two Targets Rt Hip and
Peri-Rectal mass

22. StatRT - Two Targets Rt Hip
and Peri-Rectal mass

23. Multiple Targets

24. Simple Targets

25. Mycosis Fungoides
(20/5 to Blue and 15/5 to Red)
Previous
TBE
3500/20
(using 6 or
9 MeV
electrons)
in 2003

26. Mycosis Fungoides
(20/5 to Blue and 15/5 to Red)

27. Before and After
before
before
after

28. Our Team
Medical Physics Radiation Oncology
– Jason Belec – Rob MacRae
– Brenda Clark – Laval Grimard
– Lee Gerig – Shawn Malone
– Miller MacPherson – Libni Eapen
– Gosia Niedbala – And a dozen more
– Balaz Nyiri
– Janos Szanto
Electronics
Radiation Therapy
– Gaetan Belanger
– Lynn Montgomery
– Georges Gohier
– Kathy Carty
– Greg Fox
– Najib Nassar
– Jamie Bahm
– Bev Macallum
Questions:
– Karen Vanderwerff
lmontgomery@ottawahospital.on.ca
– Kirsten Keeler
– Andre Patry
Kvanderwerff@ottawahospital.on.ca
– Sandra Hamilton