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The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques.SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments.The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations.Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests.Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition).This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.

Purpose Patients with left-sided breast cancer frequently receive deep inspiration breath-hold (DIBH) radiotherapy to reduce the risk of cardiac side effects. The aim of the present study was to analyze intra-breath-hold stability and inter-fraction breath-hold reproducibility in clinical practice. Material and methods Overall, we analyzed 103 patients receiving left-sided breast cancer radiotherapy using a surface-guided DIBH technique. During each treatment session the vertical motion of the patient was continuously measured by a surface guided radiation therapy (SGRT) system and automated gating control (beam on/off) was performed using an audio-visual patient feedback system. Dose delivery was automatically triggered when the tracking point was within a predefined gating window. Intra-breath-hold stability and inter-fraction reproducibility across all fractions of the entire treatment course were analyzed per patient. Results In the present series, 6013 breath-holds during beam-on time were analyzed. The mean amplitude of the gating window from the baseline breathing curve (maximum expiration during free breathing) was 15.8 mm (95%-confidence interval: [8.5–30.6] mm) and had a width of 3.5 mm (95%-CI: [2–4.3] mm). As a measure of intra-breath-hold stability, the median standard deviation of the breath-hold level during DIBH was 0.3 mm (95%-CI: [0.1–0.9] mm). Similarly, the median absolute intra-breath-hold linear amplitude deviation was 0.4 mm (95%-CI: [0.01–2.1] mm). Reproducibility testing showed good inter-fractional reliability, as the maximum difference in the breathing amplitudes in all patients and all fractions were 1.3 mm on average (95%-CI: [0.5–2.6] mm). Conclusion The clinical integration of an optical surface scanner enables a stable and reliable DIBH treatment delivery during SGRT for left-sided breast cancer in clinical routine.

Background Patients with left-sided breast cancer have an increased risk of cardiovascular disease (CVD) after radiotherapy (RT). While the awareness of cardiac toxicity has increased enormously over the last decade, the role of individual baseline cardiac risks has not yet been systematically investigated. Aim of the present study was to evaluate the impact of baseline CVD risks on radiation-induced cardiac toxicity. Methods Two hundred ten patients with left-sided breast cancer treated in the prospective Save-Heart Study using a deep inspiration breath-hold (DIBH) technique were analysed regarding baseline risk factors for CVD. Three frequently used prediction tools (Procam, Framingham and Reynolds score) were applied to evaluate the individual CVD risk profiles. Moreover, 10-year CVD excess absolute risks (EAR) were estimated using the individual mean heart dose (MHD) of treatment plans in free breathing (FB) and DIBH. Results The individual baseline CVD risk factors had a strong impact on the 10-year cumulative CVD risk. The mean baseline risks of the non-diabetic cohort ( n  = 200) ranged from 3.11 to 3.58%, depending on the risk estimation tool. A large number of the non-diabetic patients had a very low 10-year CVD baseline risk of ≤1%; nevertheless, 8–9% of patients reached ≥10% baseline 10-year CVD risk. In contrast, diabetic patients ( n  = 10) had significantly higher baseline CVD risks (range: 11.76–24.23%). The mean 10-year cumulative risk (Framingham score) following RT was 3.73% using the DIBH-technique (MHD:1.42Gy) and 3.94% in FB (MHD:2.33Gy), after adding a 10-year-EAR of + 0.34%(DIBH) and + 0.55%(FB) to the baseline risks, respectively. Smoking status was one of the most important and modifiable baseline risk factors. After DIBH-RT, the 182 non-smoking patients had a mean 10-year cumulative risk of 3.55% (3.20% baseline risk, 0.35% EAR) as compared to 6.07% (5.60% baseline risk, 0.47% EAR) for the 28 smokers. Conclusion In the present study, all CVD prediction tools showed comparable results and could easily be integrated into daily clinical practice. A systematic evaluation and screening helps to identify high-risk patients who may benefit from primary prevention. This could result in an even higher benefit than from heart-sparing irradiation techniques alone.

Background To report our initial clinical experience with the novel surface imaging system Catalyst™ (C-RAD AB, Sweden) in connection with an Elekta Synergy linear accelerator for daily patient positioning in patients undergoing radiation therapy. Methods We retrospectively analyzed the patient positioning of 154 fractions in 25 patients applied to thoracic, abdominal, and pelvic body regions. Patients were routinely positioned based on skin marks, shifted to the calculated isocenter position and treated after correction via cone beam CT which served as gold standard. Prior to CBCT an additional surface scan by the Catalyst™ system was performed and compared to a reference surface image cropped from the planning CT to obtain shift vectors for an optimal surface match. These shift vectors were subtracted from the vectors obtained by CBCT correction to assess the theoretical setup error that would have occurred if the patients had been positioned using solely the Catalyst™ system. The mean theoretical set up-error and its standard deviation were calculated for all measured fractions and the results were compared to patient positioning based on skin marks only. Results Integration of the surface scan into the clinical workflow did not result in a significant time delay. Regarding the entire group, the mean setup error by using skin marks only was 0.0 ± 2.1 mm in lateral, −0.4 ± 2.4 mm in longitudinal, and 1.1 ± 2.6 mm vertical direction. The mean theoretical setup error that would have occurred using solely the Catalyst™ was −0.1 ± 2.1 mm laterally, −1.8 ± 5.4 mm longitudinally, and 1.4 ± 3.2 mm vertically. No significant difference was found in any direction. For thoracic targets the mean setup error based on the Catalyst™ was 0.6 ± 2.6 mm laterally, −5.0 ± 7.9 mm longitudinally, and 0.5 ± 3.2 mm vertically. For abdominal targets, the mean setup error was 0.3 ± 2.2 mm laterally, 2.6 ± 1.8 mm longitudinally, and 2.1 ± 5.5 mm vertically. For pelvic targets, the setup error was −0.9 ± 1.5 mm laterally, −1.7 ± 2.8 mm longitudinally, and 1.6 ± 2.2 mm vertically. A significant difference between Catalyst™ and skin mark based positioning was only observed in longitudinal direction of pelvic targets. Conclusion Optical surface scanning using Catalyst™ seems potentially useful for daily positioning at least to complement usual imaging modalities in most patients with acceptable accuracy, although a significant improvement compared to skin mark based positioning could not be derived from the evaluated data. However, this effect seemed to be rather caused by the unexpected high accuracy of skin mark based positioning than by inaccuracy using the Catalyst™. Further on, surface registration in longitudinal axis seemed less reliable especially in pelvic localization. Therefore further prospective evaluation based on strictly predefined protocols is needed to determine the optimal scanning approaches and parameters.

Purpose/Objective: Reproducible patient positioning remains one of the major challenges in modern radiation therapy. Recently, optical surface scanners have been introduced into clinical practice in addition to well-established positioning systems, such as room laser and skin marks. The aim of this prospective study was to evaluate setup errors of the optical surface scanner Catalyst HD (C-RAD AB) in different anatomic regions. Material/Methods: Between October 2016 and June 2017 a total of 1902 treatment sessions in 110 patients were evaluated. The workflow of this study included conventional setup procedures using laser-based positioning with skin marks and an additional registration of the 3-dimensional (3D) deviations detected by the Catalyst system. The deviations of the surface-based method were then compared to the corrections of cone beam computed tomography alignment which was considered as gold standard. A practical Catalyst setup error was calculated between the translational deviations of the surface scanner and the laser positioning. Two one-sided t tests for equivalence were used for statistical analysis. Results: Data analysis revealed total deviations of 0.09 mm ± 2.03 mm for the lateral axis, 0.07 mm ± 3.21 mm for the longitudinal axis, and 0.44 mm ± 3.08 mm vertical axis for the Catalyst system, compared to −0.06 ± 3.54 mm lateral, 0.53 ± 3.47 mm longitudinal, and 0.19 ± 3.49 mm vertical for the laser positioning compared to cone beam computed tomography. The lowest positional deviations were found in the cranial region, and larger deviations occurred in the thoracic and abdominal sites. A statistical comparison using 2 one-sided t tests showed a general concordance of the 2 methods (P ≤ 0.036), excluding the vertical direction of the abdominal region (P = 0.198). Conclusion: The optical surface scanner Catalyst HD is a reliable and feasible patient positioning system without any additional radiation exposure. From the head to the thoracic and abdominal region, a decrease in accuracy was observed within a comparable range for Catalyst and laser-assisted positioning.

Background Intra-fraction motion represents a crucial issue in the era of precise radiotherapy in several settings, including breast irradiation. To date, only few data exist on real-time measured intra-fraction motion in breast cancer patients. Continuous surface imaging using visible light offers the capability to monitor patient movements in three-dimensional space without any additional radiation exposure. The aim of the present study was to quantify the uncertainties of possible intra-fractional motion during breast radiotherapy. Material and methods One hundred and four consecutive patients that underwent postoperative radiotherapy following breast conserving surgery or mastectomy were prospectively evaluated during 2028 treatment sessions. During each treatment session the patients’ motion was continuously measured using the Catalyst™ optical surface scanner (C-RAD AB, Sweden) and compared to a reference scan acquired at the beginning of each session. The Catalyst system works through an optical surface imaging with light emitting diode (LED) light and reprojection captured by a charge coupled device (CCD) camera, which provide target position control during treatment delivery with a motion detection accuracy of 0.5 mm. For 3D surface reconstruction, the system uses a non-rigid body algorithm to calculate the distance between the surface and the isocentre and using the principle of optical triangulation. Three-dimensional deviations and relative position differences during the whole treatment fraction were calculated by the system and analyzed statistically. Results Overall, the maximum magnitude of the deviation vector showed a mean change of 1.93 mm ± 1.14 mm (standard deviation [SD]) (95%-confidence interval: [0.48–4.65] mm) and a median change of 1.63 mm during dose application (beam-on time only). Along the lateral and longitudinal axis changes were quite similar (0.18 mm ± 1.06 mm vs. 0.17 mm ± 1.32 mm), on the vertical axis the mean change was 0.68 mm ± 1.53 mm. The mean treatment session time was 154 ± 53 (SD) seconds and the mean beam-on time only was 55 ± 16 s. According to Friedman’s test differences in the distributions of the three possible directions (lateral, longitudinal and vertical) were significant ( p  < 0.01), in post-hoc analysis there were no similarities between any two of the three directions. Conclusion The optical surface imaging system is an accurate and easy tool for real-time motion management in breast cancer radiotherapy. Intra-fraction motion was reported within five millimeters in all directions. Thus, intra-fraction motion in our series of 2028 treatment sessions seems to be of minor clinical relevance in postoperative radiotherapy of breast cancer.

ObjectiveThe impact of optical surface guidance on the use of portal imaging and the initial set-up duration in patients receiving postoperative radiotherapy of the breast or chest wall was investigated.Material and methodsA retrospective analysis was performed including breast cancer patients who received postoperative radiotherapy between January 2016 and December 2016. One group of patients received treatment before the optical surface scanner was installed (no-OSS) and the other group was positioned using the additional information derived by the optical surface scanner (OSS). The duration of the initial set-up was recorded for each patient and a comparison of both groups was performed. Accordingly, the differences between planned and actually acquired portal images during the course of radiotherapy were compared between both groups.ResultsA total of 180 breast cancer patients were included (90 no-OSS, 90 OSS) in this analysis. Of these, 30 patients with left-sided breast cancer received radiotherapy in deep inspiration breath hold (DIBH). The mean set-up time was 10 min and 18 s and no significant difference between the two groups of patients was found (p = 0.931). The mean set-up time in patients treated without DIBH was 9 min and 45 s compared to 13 min with DIBH (p < 0.001), as portal imaging was performed in DIBH. No significant difference was found in the number of acquired to the planned number of portal images during the entire radiotherapy treatment for both groups (p = 0.287).ConclusionOptical surface imaging is a valuable addition for primary patient set-up. The findings confirm that the addition of surface-based imaging did not prolong the clinical workflow and had no significant impact on the number of portal verification images carried out during the course of radiotherapy.

An amendment to this paper has been published and can be accessed via the original article.

The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques. SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments. The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations. Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests. Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition). This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.

Background There is a potential for adverse cardiovascular effects in long-term breast cancer survivors following adjuvant radiotherapy (RT). For this purpose, the deep inspiration breath-hold technique (DIBH) has been introduced into clinical practice, to maximally reduce the radiation dose to the heart. However, there are a variety of DIBH delivery techniques, patient positioning and visual patient feedback mechanisms. The aim of the present study was to evaluate the application of radiotherapy in DIBH using the Catalyst TM /Sentinel TM system, with a special emphasis on treatment planning and dosimetric plan comparison in free breathing (FB) and DIBH. Patients and methods A total of 13 patients with left-sided breast cancer following breast conserving surgery were included in this prospective clinical trial. For treatment application the Catalyst TM /Sentinel TM system (C-RAD AB, Uppsala, Sweden) was used and gating control was performed by an audio-visual patient feedback system. CT and surface data were acquired in FB and DIBH and dual treatment plans were created using Pencil Beam and Collapsed Cone Convolution. Dosimetric output parameters of organs at risk were compared using Wilcoxon signed-rank test. Central lung distance (CLD) was retrieved from iView TM portal images during treatment delivery. Results The system contains a laser surface scanner (Sentinel TM ) and an optical surface scanner (Catalyst TM ) interconnected to the LINAC systems via a gating interface and allows for a continuous and touchless surface scanning. Overall, 225 treatment fractions with audio-visual guidance were completed without any substantial difficulties. Following initial patient training and treatment setup, radiotherapy in DIBH with the Catalyst TM /Sentinel TM system was time-efficient and reliable. Following dual treatment planning for all patients, nine of 13 patients were treated in DIBH. In these patients, the reduction of the mean heart dose for DIBH compared to FB was 52 % (2.73 to 1.31 Gy; p  = 0.011). The maximum doses to the heart and LAD were reduced by 59 % (47.90 to 19.74 Gy; p  = 0.008) and 75 % (38.55 to 9.66 Gy; p  = 0.008), respectively. In six of the nine patients the heart completely moved out of the treatment field by DIBH. The standard deviation of the CLD varied between 0.12 and 0.29 cm (mean: 0.16 cm). Conclusion The Catalyst TM /Sentinel TM system enabled a fast and reliable application and surveillance of DIBH in daily clinical routine. Furthermore, the present data show that using the DIBH technique during RT could significantly reduce high dose areas and mean doses to the heart. Trial registration DRKS: DRKS00010929 registered on 5. August 2016.