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
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
