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MOTION MANAGEMENT IN RADIOTHERAPY
DR KANHU CHARAN PATRO
RADIATION ONCOLOGIST-THE ARJUN
SBRT WORK FLOW
Simulation Planning
TX
Deliver
y
Motion Verification Localization
Motion Management
Delivery
EVERYBODY IS A KING
WHEN EVERYTHING IS INSIDE THE RING [PTV]
PUSHING BACKWARD AND FORWARD
ALWAYS NOT THE POINT OF INTEREST
OAR
TARGET
5
BECAUSE
ORGANS DO NOT FOLLOW STATUE GAME
SYSTEMATIC
VS
RANDOM
12/12/2018
12/12/2018
12/12/2018
THE HYSTERICAL MOTION
MOTION MANAGEMENT
1.Intrafraction
2.Interfraction
GATING
Delivery of radiation within a specified part of the patient’s
breathing cycle termed ‘the gate’. Phase or amplitud...
PHASE BASED TREATMENT-
CHOOSING PART OF DUTY CYCLE
12/12/2018
HOLDING
Assists breath-hold by use of a valved spirometer. Often at
moderate or deep breath-hold.
Can reduce motion artefa...
VOLUNTARY BREATH HOLD USING WIRELESS DOOR BELL
1. You can practice voluntary breath hold/DIBH for
breast /end expiratory b...
ABDOMINAL COMPRESSING
Abdominal compression plate can be used in conjunction
with stereotactic frames to limit diaphragmat...
TRACKING
Real-time delivery of radiation with simultaneous tracking
of internal or external surrogate.
Can significantly r...
12/12/2018
12/12/2018
SURROGATE MARKERS FOR TRACKING
• BILLIARY STENT
• INTERNAL FIDUCIARIES
• BONY MARKERS
Assessment of motion
• Fluoroscopy mode
• 4D CT
• SLOW CT
• MULTIPHASE CT
4D CT
Enables correlation of computed tomography scanning with
patient’s respiration. Breathing cycle monitored by using
e...
SLOW CT
Computed tomography scan operated slowly and/or
multiple slices taken are averaged, i.e. multiple phases of
respir...
WHICH MOTION MANAGEMENT
SYSTEM IS BETTER?
GOSSIP- WHOSE SPOUSE IS BETTER?
ANSWER- WHAT MANAGEMENT ACQUIRES
I WILL TELL ABOUT THE MOTION MANAGEMENT
IT IS ONE OF THE IMPORTANT SBRT COMPONENT [1]
PTV HAS TWO COMPONENT, SET UP ERROR ...
RHYME-CONTD.
GATING, COMPRESSING, TRACKING, AND HOLDING
ARE THE FOUR TYPES FOR MOTION MANAGING [7]
COMPRESS THE ABDOMEN WI...
RHYME-CONTD.
ELEKTA ABC IS KNOWN AS ACTIVE BREATH COORDINATOR
AUTO HOLDING AT END EXPIRATOR OR END INSPIRATOR [13]
EXHALE ...
RHYME-CONTD.
SOFTWARE CALCULATES VARIOUS INTENSITY PROJECTIONS
MIP, AIP, Min-IP ARE TYPES OF DIFFERENT INTENSITY PROJECTIO...
RHYME-CONTD.
ANZAI SYSTEM GATING FROM SIEMENS
IT WORKS THROUGH BELT BY PRESSURE CHANGES [25]
IN SHORT TRACKING AND CRACKIN...
THANKS
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
MOTION MANAGEMENT IN RADIOTHERAPY
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MOTION MANAGEMENT IN RADIOTHERAPY

  1. 1. MOTION MANAGEMENT IN RADIOTHERAPY DR KANHU CHARAN PATRO
  2. 2. RADIATION ONCOLOGIST-THE ARJUN
  3. 3. SBRT WORK FLOW Simulation Planning TX Deliver y Motion Verification Localization Motion Management Delivery
  4. 4. EVERYBODY IS A KING WHEN EVERYTHING IS INSIDE THE RING [PTV]
  5. 5. PUSHING BACKWARD AND FORWARD ALWAYS NOT THE POINT OF INTEREST OAR TARGET 5
  6. 6. BECAUSE ORGANS DO NOT FOLLOW STATUE GAME
  7. 7. SYSTEMATIC VS RANDOM
  8. 8. 12/12/2018
  9. 9. 12/12/2018
  10. 10. 12/12/2018
  11. 11. THE HYSTERICAL MOTION
  12. 12. MOTION MANAGEMENT 1.Intrafraction 2.Interfraction
  13. 13. GATING Delivery of radiation within a specified part of the patient’s breathing cycle termed ‘the gate’. Phase or amplitude based. Uses external respiration signals e.g. infrared, spirometry, thermistors or internal fiducials. internal fiducials. Can significantly reduce margins required, therefore potential decrease in dose to OARs. Imaging and treatment synchronised with patient’s breathing cycle Increases time to deliver treatment. Assumes that fiducial signal and its periodicity is reflective of tumour motion. Requires regular imaging and therefore increased imaging dose. More complex quality assurance procedures
  14. 14. PHASE BASED TREATMENT- CHOOSING PART OF DUTY CYCLE 12/12/2018
  15. 15. HOLDING Assists breath-hold by use of a valved spirometer. Often at moderate or deep breath-hold. Can reduce motion artefacts. Improvements in dose to organs at risk. Potential for dose escalation compared with free-breathing technique Patient selection important; non-compliance of patients with poor respiratory function. Increase in quality assurance procedures
  16. 16. VOLUNTARY BREATH HOLD USING WIRELESS DOOR BELL 1. You can practice voluntary breath hold/DIBH for breast /end expiratory breath hold for abdomen SBRT system when there is no motion management system available. 2. Needs proper training to the patient and the technologist 3. When patient inside the treatment room he/she holds the breath [sends signal] and technologist switch on the beam. 4. When patient exhausted with breath holding again sends signal , then technologist switch off the beam . 5. Procedure repeats till the total treatment is over. 6. For all this procedure patient needs to send signal by various means . it may cause positioning error. 7. Wireless house bell will help this condition. Just switching the bell [on hand of the patient], signal sending will be easier and more practical. CLINICAL EXPERIENCE 22nd OCT 2018/PHYSICS
  17. 17. ABDOMINAL COMPRESSING Abdominal compression plate can be used in conjunction with stereotactic frames to limit diaphragmatic motion by forced shallow breathing. Permits normal respiration while reducing diaphragmatic and hence tumor motion. May be unsuitable for obese patients or those with poor respiratory function. Can lead to more erratic breathing in some instances. Requires regular imaging due to difficulties associated with plate position reproducibility
  18. 18. TRACKING Real-time delivery of radiation with simultaneous tracking of internal or external surrogate. Can significantly reduce margins required, therefore subsequent decrease in dose to OARs. Decreased time to deliver treatment compared to gating Increased imaging dose with fluoroscopy.
  19. 19. 12/12/2018
  20. 20. 12/12/2018
  21. 21. SURROGATE MARKERS FOR TRACKING • BILLIARY STENT • INTERNAL FIDUCIARIES • BONY MARKERS
  22. 22. Assessment of motion • Fluoroscopy mode • 4D CT • SLOW CT • MULTIPHASE CT
  23. 23. 4D CT Enables correlation of computed tomography scanning with patient’s respiration. Breathing cycle monitored by using external surrogate Reduced blurring/artefact compared with slow computed tomography. Can evaluate mean tumour position and tumour motion correlation with surrogates and surrounding OARs. Increase in imaging dose compared with conventional computed tomography scan. May be unreliable in irregular breathing patterns leading to artefact
  24. 24. SLOW CT Computed tomography scan operated slowly and/or multiple slices taken are averaged, i.e. multiple phases of respiration are recorded by slice Generally available on most computed tomography scanners. Loss of resolution, which may lead to tumour blurring and subsequent increase in observer error in tumour and OAR delineation
  25. 25. WHICH MOTION MANAGEMENT SYSTEM IS BETTER?
  26. 26. GOSSIP- WHOSE SPOUSE IS BETTER?
  27. 27. ANSWER- WHAT MANAGEMENT ACQUIRES
  28. 28. I WILL TELL ABOUT THE MOTION MANAGEMENT IT IS ONE OF THE IMPORTANT SBRT COMPONENT [1] PTV HAS TWO COMPONENT, SET UP ERROR AND ITV MOTION MANAGEMENT IS MAINLY FOR REDUCTION IN ITV [2] PATIENT COUNSELING IS THE IMPORTANT STEP AUDIO VISUAL TRAINING IMPROVES THE RESP [3] MOTION IS PERISTALSIS, FILLING AND RESPIRATION IT MAY BE INTERFRACTION OR INTRAFRACTION [4] DO NOT THINK TUMOR MOVES IN LINEAR DIRECTION TUMOR TAKES THE PATH OF HYSTERICAL MOTION [5] BETTER TO CONSIDER RADIOTHERAPY WITH MOTION MANAGEMENT WHEN THERE IN MORE THAN FIVE MILLIMETER MOVEMENT [6] RHYME
  29. 29. RHYME-CONTD. GATING, COMPRESSING, TRACKING, AND HOLDING ARE THE FOUR TYPES FOR MOTION MANAGING [7] COMPRESS THE ABDOMEN WITH BODY FIX OR BELT IT CAUSES SWALLOW BREATHING AT ITS BEST [8] CUFF ALSO USED TO INITIATE PNEUMATIC PRESSURE PNEUMATIC PRESSURE ACT AS ABDOMINAL COMPRESSOR [9] TRACKING THROUGH EXTERNAL AND INTERNAL FIDUCIARIES MOSTLY AVAILABLE IN CYBER KNIFE AND EXACT TRAC FACILITIES [10] RESPIRATORY MANAGEMENT IN CYBERKINFE IS ALSO THERE WITH TRACKING THEY CALL IT AS SYNCHRONY HERE [11] CALYPSO USES ELECTROMAGNETIC WAVE FOR TRACKING IT USES INTERNAL FIDUCIARY FOR GPS TRACKING [12]
  30. 30. RHYME-CONTD. ELEKTA ABC IS KNOWN AS ACTIVE BREATH COORDINATOR AUTO HOLDING AT END EXPIRATOR OR END INSPIRATOR [13] EXHALE POSITION IS MORE REPRODUCIBLE INHALE POSITION MORE NORMAL LUNG SPARABLE [14] RPM IS REAL TIME POSITION MANAGEMENT GATING THROUGH PHASE OR AMPLITUDE MANAGEMENT [15] PHASE GATING IS TO TRAET THE PART OF RESPIRATORY CYCLE THIS TREATING PHASE IS CALLED DUTY CYCLE [16] AMPLITUDE GATING IS ALSO POSSIBLE BY TREATING AT FIXED RESPIRATORY THRESHOLD LEVEL [17] 4D CT AND REFLECTOR ARE ESSENTIAL COMPONENTS RETROSPECTIVE AND PROSPECTIVE SORTING ARE TWO PROPONENTS [18]
  31. 31. RHYME-CONTD. SOFTWARE CALCULATES VARIOUS INTENSITY PROJECTIONS MIP, AIP, Min-IP ARE TYPES OF DIFFERENT INTENSITY PROJECTIONS [19] IF NO MOTION MANAGEMENT SYSTEM IS AVAILABLE TRY VOLUNTARY BREATH HOLD IF POSSIBLE [20] YOU CAN CALCULATE ITV BY VARIOUS PROCESS FLUOROSCOPY, 4DCT, SLOW CT AND MULTIPHASE PROCESS [21] ELEKTA SYMMETRY IS MAINLY FOR LUNG MOTION IT IS MEANT FOR PROSPECTIVE IMAGE ACQUISITION [22] VISION RT AND CATALYST ARE MAINLY SURFACE GATING OSMS HAS NO MARKER OR FIDUCIARY FOR THESE GATING [23] PHILIPS BELLOWS SYSTEM ALSO IS FOR GATING IT DOES NOT USE MARKER OR FIDUCIARY FOR THE GATING [24]
  32. 32. RHYME-CONTD. ANZAI SYSTEM GATING FROM SIEMENS IT WORKS THROUGH BELT BY PRESSURE CHANGES [25] IN SHORT TRACKING AND CRACKING, GATING AND SHOOTING COMPRESSING AND CRUSHING, HOLDING AND SCOLDING [26]
  33. 33. THANKS
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