PANCREATIC SBRT SIMULATION
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This document discusses simulation techniques and tips for pancreatic malignancy radiosurgery. It covers the workflow from planning to delivery and various techniques for motion management including gating, tracking, abdominal compression and breath holds. Imaging protocols including triple phase CT and PET scans are described for target and organ at risk visualization. Steps for patient preparation, positioning, immobilization and counseling are also outlined.
![IMMOBILIZATION
тАв NO
тАв ORFIT
тАв VACLOK
тАв BOTH[ORFIT+VACLOK]
тАв BODY-FIX
10/28/2018 24](https://image.slidesharecdn.com/maxpanc-181028124451/85/PANCREATIC-SBRT-SIMULATION-24-320.jpg)
![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.
10/28/2018 46](https://image.slidesharecdn.com/maxpanc-181028124451/85/PANCREATIC-SBRT-SIMULATION-46-320.jpg)
![Fiduciaries
stent
Liver[oar]
Pancreas[target]
10/28/2018 49](https://image.slidesharecdn.com/maxpanc-181028124451/85/PANCREATIC-SBRT-SIMULATION-49-320.jpg)
![Where is the Target?
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE
10/28/2018 66](https://image.slidesharecdn.com/maxpanc-181028124451/85/PANCREATIC-SBRT-SIMULATION-66-320.jpg)
PANCREATIC SBRT SIMULATION
- 1. Simulation tips and Techniques in Pancreatic malignancy. DR KANHU CHARAN PATRO 10/28/2018 HEPATOBILLIARY/DELHI MAX/28th OCT 2018 1 A LEARNERтАЩS PROSPECTIVE
- 2. SBRT Work Flow Simulation Planning TX Deliver y Motion Verification Localization Motion Management Delivery 10/28/2018 2
- 3. PUSHING BACKWARD AND FORWARD AT A TIME DIFFICULT BUT NOT IMPOSSIBLE OAR TARGET 10/28/2018 3
- 5. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 5
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- 7. THE SPHERE RULE 10/28/2018 7 V=4/3с┤лr3
- 9. REDUCTION IN PTV тАв Custom immobilization тАв Respiratory management тАв Image guidance PTV PTV 10/28/2018 9
- 10. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 10
- 11. PREPARATION тАв TUMOR BOARD тАв PATIENT DOCUMENTS тАв INVESTIGATION REPORT тАв COUNSELING тАв EMPTY STOMACH тАв IMMOBILIZATION DEVICES тАв AVAILABLE MOTION MANAGEMENT тАв IMAGING IN YOUR MIND тАв GO AHEAD 10/28/2018 11
- 12. FULL VS EMPTY STOMACH 10/28/2018 12
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- 16. HANDLING STOMACH FILLING 1. Variations in gastric filling may lead to significant intrafraction differences dose to normal stomach. 2. To mitigate this most panelists recommended keeping patients NPO for 2-3 hours before simulation and each treatment. 10/28/2018 16
- 17. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 17
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- 23. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 23
- 24. IMMOBILIZATION тАв NO тАв ORFIT тАв VACLOK тАв BOTH[ORFIT+VACLOK] тАв BODY-FIX 10/28/2018 24
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- 28. Body fix with compressor 10/28/2018 28
- 29. 6 or 4 clamp with vaclok and without vaclok 6 clamp does not need a vaclok and 4 clamp needs a vaclok 10/28/2018 29
- 30. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 30
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- 33. MOTION MANAGEMENT 1.Oar movement 2.Pancreas movement 1.Intrafraction 2.Interfraction 10/28/2018 33
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- 37. Normal Treatment ITVBased Treatment Gating Based Treatment RealTime Tracking BasedTreatment ForceShallow Breath BasedTreatment Motion ManagementTechniques PT V PTV PTV PTV PTV ITV 10/28/2018 37
- 38. GHAT ROAD AHEAD G GATING H HOLDING A ABDOMINAL COMPRESSING T TRACKING 10/28/2018 38
- 39. GATING AND SHOOTING TRACKING AND CRACKING COMPRESSING AND BREAKING HOLDING AND CHOPPING 10/28/2018 39
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- 42. ABDOMINAL COMPRESSION 1. Abdominal compression plate can be used in conjunction with stereotactic frames to limit diaphragmatic motion by forced shallow breathing. 2. Permits normal respiration while reducing diaphragmatic and hence tumor motion. 3. May be unsuitable for obese patients or those with poor respiratory function. Can lead to more erratic breathing in some instances. 4. Requires regular imaging due to difficulties associated with plate position reproducibility 10/28/2018 42
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- 44. HOLDING 1. Assists breath-hold by use of a valved spirometer. Often at moderate or deep breath-hold. 2. Can reduce motion artifacts. Improvements in dose to organs at risk. 3. Potential for dose escalation compared with free- breathing technique 4. Patient selection important; non-compliance of patients with poor respiratory function. Increase in quality assurance procedures. 10/28/2018 44
- 45. тАв End expiratory тАв End Inspiratory 10/28/2018 45
- 46. 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. 10/28/2018 46
- 47. TRACKING 1. Real-time delivery of radiation with simultaneous tracking of internal or external surrogate markers. 2. Can significantly reduce margins required, therefore subsequent decrease in dose to OARs. 3. Decreased time to deliver treatment compared to gating. 10/28/2018 47
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- 51. SURROGATE MARKERS тАв BILLIARY STENT тАв INTERNAL FIDUCIARIES тАв BONY MARKERS 10/28/2018 51
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- 54. GATING 1. Delivery of radiation within a specified part of the patientтАЩs breathing cycle termed тАШthe gateтАЩ. 2. Phase or amplitude based. Uses externat respiration signal e.g. infrared, spirometry, thermistors or internal fiducials. internal fiducials. 3. Can significantly reduce margins required, therefore potential decrease in dose to OARs. 4. Imaging and treatment synchronised with patientтАЩs breathing cycle 10/28/2018 54
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- 56. PHASE BASED TREATMENT- CHOOSING PART OF DUTY CYCLE 10/28/2018 56
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- 58. SLOW CT- ONE SLICE MULTIPLE PHASES 1. Computed tomography scan operated slowly and/or multiple slices taken are averaged, i.e. multiple phases of respiration are recorded by slice 2. Generally available on most computed tomography scanners 3. Loss of resolution, which may lead to tumour blurring and subsequent increase in observer error in tumour and OAR delineation 10/28/2018 58
- 59. 4D CT 1. Enables correlation of computed tomography scanning with patientтАЩs respiration. Breathing cycle monitored by using external surrogate 2. Reduced blurring/artefact compared with slow computed tomography. Can evaluate mean tumour position and 3. tumour motion correlation with surrogates and surrounding OARs. 4. Increase in imaging dose compared with conventional computed tomography scan. May be unreliable in irregular breathing patterns leading to artefact 10/28/2018 59
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- 61. MULTI PHASE CT SCAN DEEP EXPIRATORY DEEP INSPIRATORY NORMAL BREATHING ITV GENERATION 10/28/2018 61
- 62. WHICH MOTION MANAGEMENT SYSTEM IS BETTER 10/28/2018 62
- 63. GOSSIP- WHOSE SPOUSE IS BETTER? 10/28/2018 63
- 65. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 65
- 66. Where is the Target? SPARE THE ROD AND SPOIL THE CHILD DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE 10/28/2018 66
- 67. IMAGING- TRIPHASIC CT SCAN 10/28/2018 67
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- 73. IMAGING PROTOCOL- NEGATIVE/NEUTRAL CONTRAST 10/28/2018 73
- 74. WATER RATHER THAN CONTRAST 10/28/2018 74
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- 76. 1. Use water rather than contrast 2. Pancreatic phase instead of the arterial phase. Pancreatic phase refers to the late arterial phase (typically 40-45 sec after contrast injection) during IV contrast. Pancreatic Protocol 10/28/2018 76
- 77. VISUALIZATION OF PANCREATIC TUMOR - CT SCAN тАв Lesion detection, localization and characterization. тАв Hypoenhancing mass with focal contour abnormality тАв The hypo-enhancement is accounted for by the desmoplastic and hypovascular nature of the tumor тАв On dynamic images, the pancreatic phase shows the greatest attenuation differentiation and is therefore more sensitive than the portal-venous phase in detection of these lesions. тАв However, in up to 10% of cases, pancreatic cancer can be iso- attenuating to pancreatic parenchyma & Secondary signs will help тАв These secondary signs include pancreatic ductal dilatation and parenchymal atrophy distal to the lesion with abrupt change in ductal caliber at the site of lesion . 10/28/2018 77
- 78. VISUALIZATION OF PANCREATIC TUMOR - MRI тАв Magnetic resonance imaging (MRI) with (MRCP) has emerged as a reliable tool . тАв Negative oral contrast is administered to reduce the signal from the overlying stomach and duodenum . тАв Dynamic post contrast images should be obtained 25, 70, and 120 sec after the gadolinium contrast injection. тАв Ideally, field strength should be тЙе 1.0 Tesla with fast imaging sequences. 10/28/2018 78
- 79. VISUALIZATION OF PANCREATIC TUMOR - PET 1. Yields high-resolution anatomic information for surgical and radio-therapeutic planning and functional information . 2. 30% increase in gross tumor volume in five patients owing to the incorporation of additional lymph node metastatic lesions and extension of the primary tumor beyond the volume defined with CT 3. Triple phase contrast enhanced PET CT A. NON ENHANCED PHASE B. CONTRAST PHASE/ARTERIAL PHASE C. VENOUS PHASE 10/28/2018 79
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- 81. TRIPLE PHASE PET CT- NON ENHANCE/ART/VENOUS 10/28/2018 81
- 82. PET VOLUME AND CT VOLUME 10/28/2018 82
- 83. PET VOLUME FOR RADIATION 10/28/2018 83
- 84. Pet CT planning 10/28/2018 84
- 86. STEPS тАв WHY SO IMPORTANT? тАв PREPARATION тАв POSITIONING тАв IMMOBILIZATION тАв MOTION MANAGEMENT тАв IMAGING тАв EXECUTION 10/28/2018 86
- 88. EXECUTION тАв Cat watch тАв Copy cat тАв Cat movement тАв Staff training 10/28/2018 88
- 89. Take a photograph 10/28/2018 89
- 92. TRAIN YOUR RTT 10/28/2018 92
- 96. TRAFFIC LIGHT IGRT APP 10/28/2018 96
- 97. тАв Supine with hands up тАв Nil/orfit/vaclok/both/body fix тАв Empty stomach тАв Water in place of oral contrast тАв Pancreatic protocol тАв Triple fusion тАв Gating/holding/compression/tracking COUNSELING/GUIDING HOSPITAL TAKE HOME MESSAGE 10/28/2018 97
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- 102. Thank you тАвAudience тАвConference organizers тАвMax hospital 10/28/2018 102
- 103. 10/28/2018 12:44:53 PM 103
- 104. Just тАЬDoing ItтАЭ is not good enough ! You must know тАЬwhatтАЭ to do and тАЬwhereтАЭ to do it ! 10/28/2018 12:44:53 PM 104
- 105. SOP IN STEREOTAXY BRAIN TO DRAIN VISKAHAPATANAM 10/28/2018 105