SGRT Birmingham 2022 Julie Davies, Lead Therapeutic Radiographer   Christie at Oldham 

1. SGRT for DIBH -The Christie
at Oldham Experience.
“from Zero to Hero”
Julie Davies Lead Radiographer
The Christie at Oldham

2. The Christie
•Multi-sited, with 4
centres based
Withington, Oldham,
Salford and Macclesfield
Catchment area over
100 sq miles
•Population 3.2 million

3. Pre SGRT..
• A solution was required for DIBH in Breast patients
• The Christie treats approximately 1600 breast patients per year, 800 of
which have left sided disease or require treatment for internal mammary
chain (IMC)
• A spirometer based technique was available but due to demand this
was restricted in numbers to those with most need and also was only
offered in Withington so patients were required to travel even if they
lived nearer a satellite site.

4. And then COVID
• Business case was making good progress but then Covid struck….
Everything stopped
• However we were then thrown a life line when the Trust wanted to look
at all options that would improve workflow and support bio security;
• Would SGRT offer ?
• Improved treatment times
• Less patient contact
• Reduction of spirometer based treatments
• Optimum treatments accessible at all satellites ensuring footfall was
distributed
• The task for the team was then to implement in a short timeframe

5. Timeline of Project
• Oldham install and acceptance
Mid October 2020
• Withington install and acceptance
Early November 2020
• Salford install and acceptance
End November 2020
COMPLETED BY END NOVEMBER 2020 !!
• Macclesfield install completed at Build
• January 2022
• 7 AlignRT systems across 4 sites
• 4 Gate CT / SIMRT systems across 4 sites

6. Oldham Timeline
Site Progress Date Completed
Oldham Response kits installed
IT connections
Electrical work
SGRT install
Physics commissioning
Training
Engineers
Rads and physics –
Implementation team
Departmental training / Work
instructions
Go Live Free Breath SGRT
Validation
First DIBH
DIBH as standard left breast
patients
6th October 20
8th October
15th October
19th October
26th October
Dec
9-10th Dec
Dec 14th
18th Jan 21
March 21
May 21

7. Experience
• As with all new technology confidence in a new system was required
and a clinical validation phase was established. This also allowed
familiarisation with the system prior to DIBH treatments which was
the ultimate aim
• This involved a hybrid technique for the initial patients to establish
the differences between the moves from previous workflow to SGRT
• Patients were imaged daily

8. Phase 1 Results
•Translational Deltas:
Mean translations are close to zero (within 0.2cm)
No systematic offset of the system
Correcting for these translations resulted in good set up
All MV imaging in tolerance and therefore no corrections were
necessary to the set up
VRT
(cm)
LNG
(cm)
LAT
(cm)
YAW
(deg)
Roll
(deg)
Pitch
(deg)
Mean delta 0.0 -0.2 -0.1 -0.4 -0.3 0.4

9. Phase 1 Results
• Our pre-SGRT workflow also included the recording of FSD’s this data
was also checked in the validation phase
• FSD:
• Results - monitoring a full surface potentially negates the need for
checking the distance at individual points.
• Lung depth:
Difference from Pinnacle FSD (cm)
SGRT patients Pre-SGRT patients
Isocentre FSD Med FSD Lat FSD Isocentre FSD Med FSD Lat FSD
Mean -0.1 -0.2 -0.3 0.1 -0.1 -0.2
Max 0.5 0.5 0.5 0.7 0.5 0.7
Min -1.0 -1.2 -1.0 -0.6 -1.1 -1.0
Difference in lung depth compared to Pinnacle DRR (cm)
SGRT patients Pre SGRT patients
Mean 0.1 -0.1
Max 0.5 0.6
Min -0.1 0.8

10. Phase 2
• Progression from positioning only to Monitoring with Gating in preparation for
DIBH patients. Removal of the hybrid approach, positioning using SGRT
system
• Again this gave the staff experience in preparation for DIBH
• A further group of patients were imaged daily.
Imaging
• During validation 140 images were taken, 1 image required correction
• A smaller sample for comparison was taken pre SGRT which identified a
correction rate of 30%, this resulted in an additional image the following day.
Therefore further time savings were identified.
• For standard positioning (NON DIBH) we compared positioning times pre SGRT
with post SGRT inclusive of imaging and identified a time saving on average of
2 minutes 14 seconds per patient

11. DIBH
• Further support and training was available in scanner for GateCT
• Clinical support specialist available on site for day 1 of scanning and
treatment
• Initially time slots were increased in scanner these have now reduced
as experience has grown. No additional time is required for non-DIBH
and on average and additional 10 minutes is required for a DIBH
appointment
• Patients are coached and scanned on the same day
• If patients are anxious further time is invested at scan to ensure a better
treatment experience for the patient
• First patients treated with DIBH in March 21 and followed by other
Christie sites in April. From May 21 all left sided breast patients at all
locations received DIBH via AlignRT
• So far only 4 patients at Oldham have not tolerated DIBH due to co-
morbidities

12. Clinical Implementation – DIBH
•Two scans performed
Localise on Free Breathe scan (low dose)
Plan and treat on Breath Hold scan
•External contours from Pinnacle for use in AlignRT
“SKIN”
“FREE_BREATHE_SKIN”

13. DIBH Patient Data
•Initially our average treatment time for DIBH was 16
minutes 12 seconds with a range from 9 -25 minutes. This
included 2 breast cast patients which take slightly longer.
•Spirometer DIBH time slot allocation was 30 minutes, so in
comparison average time saving 13 minutes 48 seconds
•At Oldham see-saw effect - increase in DIBH time vs
decrease in standard positioning times
•Compliance with SGRT is far greater than with the
spirometer method - less restrictions such as false teeth /
claustrophobia / age.
•Patients always maintain control!

14. DIBH Patient Data
•Every patient is an individual and some may vary
but if they proceed through scan every patient has
managed breath hold

15. SGRT and Breast Casts
•Patients with larger mobile breasts and increased
skin folds can prove a technical challenge.
•The advantages of thermoplastic cast gives the
breast support in a reproducible position whilst
reducing the planned volume.

16. Thermoplastic Breast Cast
• Formation of the breast cast with the thermoplastic
attaching directly to the CQUAL board.
• SGRT is used for positioning as standard, the cast is
customised to ensure the target volume can be visualised.
• check the customised ROI could be tracked.

17. Effectiveness of a breast cast
• The Original plan shows the field breast falling inferior over the
abdomen and large mammary fold identified.
• Rescan requested with breast cast.
• Result achieved 3.2cm field reduction and mammary fold lifted
away from the body

18. Thermoplastic breast cast
• The cast was made lifting the breast laterally off the
latissimus dorsi.
• Breast cast was made and breath hold achieved.
• Result: reduced cardiac tissue 1.77cm

19. SGRT Treatment preparation
• ROI is already delineated and replicated
Cast ROI Cast ROI Standard ROI
• No additional change to current practice

20. Recent Upgrade in Scanner
• Currently undergoing a replacement programme which is replacing all
major equipment including linacs and scanner
• The scanner replacement also came with upgrade from GateCT to
SIMRT and this has brought several advantages
• Active prompts to ensure connectivity between scanner and SIMRT
software
• Second terminal (patient side) within the scanner room improves
workflow and communication
• Allows tracking of the patient and the setting of a target Breath-hold.
The range can be manipulated (+/- 1.5 as the linac gates at 3mm) to
match the gating tolerance on the treatment floor – this ensures that the
patient can achieve a Breath Hold that will allow an efficient treatment
delivery

21. Scanner Upgrade
• The addition of the RTC in the scanner allows staff to explain and
educate the patient in its use and how it will assist them during
treatment. It also highlighted the patients that can-not use the RTC
• The trace is easy to interpret, amplitude is quick to read, all tracking is
automatically recorded in the patients file.
• The ability to have pre-set protocols reduces the error for incorrect pitch
selection which will be used during 4d scans.

22. Linac Replacement Programme
•Currently replacing linacs 1 at a time over a period
of 1 year. In order to do this we had to look at our
workload and categorisation of patients so in the
event of a breakdown we could ensure patients
were not compromised and we stayed in
accordance with
The Standards and Guidelines for the Management
of Unscheduled Treatment Interruptions. RCR

23. SGRT Contingency
• What would we do if…..
Loss of SGRT – revert back to old method of set up accepting it would
take longer. Frequency –since install October 20 we have never had
prolonged downtime. We do re-boots occasionally and occasional loss of
connection which is quickly rectified.
Loss of imaging- if day 1 delay patient. Prior to replacement data was run
on patients treated and imaged using SGRT
Non DIBH - 1176 images were reviewed only 3.7% were out of tolerance
DIBH breast -1425 images were reviewed only 1.1% were out of
tolerance
Therefore based on this data clinicians were happy to proceed without
imaging whilst the issue was resolved.

24. Oldham Patient Data
•From Feb 21 treated
4870# breast patients using the SGRT system
From March 21 DIBH introduced
2190 # DIBH delivered
Trust wide
16,231 # breast patients using the SGRT system
9,072 # DIBH

25. Moving forward
•Within a short space of time all Christie sites offered DIBH
to all left sided breast patients.
•Equitable access for all patients closer to home
•Although not currently embarking on a tattoo less process
there have been several occasions where patients have
refused tattoos or difficulties identifying them have been
resolved with SGRT. No requirement to rescan the patient
•Upgrade to version 6 AlignRT Advance is imminent
•Utilise the system for positioning at other anatomical sites
as we can clearly see its advantages

26. Acknowledgements
• Huge thanks to all disciplines across The Christie who have contributed
so much to ensure SGRT is operational and benefiting patients.
• Massive achievement in a short space of time, especially challenging
during a pandemic.
• VisionRT team for their support and collaboration
• Christie at Oldham team, Kate Buttrum and Craig Jones
• Queen Elizabeth in Birmingham and Guys and St Thomas for their
willingness to share