THE TECHNOLOGY AND USES OF ON-TREATMENT IMAGING IN RADIOTHERAPY

Venue: Stewart House, LondonCPD: 5 CREDITS

24 MARCH

2015

View the full programme and register at: www.bir.org.uk

• Room1Primers for the non-specialistsSessionorganisedbyDrDavid

Wilson,ConsultantInterventional

MSKRadiologist,OxfordUniversity

HospitalsNHSTrust

• Room2Radiation protection: current issues in molecular imaging and radiotherapySessionorganisedbyMrAndy

Rogers,HeadofRadiationPhysics,

NottinghamUniversityHospitals

NHSTrust

Save the date

• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath

Gnanasegaran,Consultant

PhysicianinNuclearMedicine,

StThomas’Hospital

• Room2Emergency radiology - advances in trauma imaging and Essentials for the radiology traineeSessionorganisedbyDrHardi

Madani,RadiologyRegistrar,Royal

FreeLondonHospitaland

DrAusamiAbbas,Cardiothoracic

RadiologyPostCCT

Day 2Day 1

BIR ANNUAL CONGRESS 20154–5 NOVEMBER

LONDON

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Save the date

Day 2

Welcome and thank you for coming to ‘The technology and uses of on-treatmentimaginginradiotherapy’organisedbyTheBritishInstituteofRadiology.

Wewishyouaveryenjoyableandeducationalexperience.

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Yourcertificateofattendancewillbeemailedtoyouwithinthenext2weeksonceyouhavecompletedtheonlineeventsurveyat:

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BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference

Please take time to visit their exhibition stands to find out moreabout the services they offer

2

Programme

09:15 Registration and refreshments

09:40 Welcome and introduction DrKeithLangmack,HeadofRadiotherapyPhysics, NottinghamUniversitiesNHSTrust

09:45 Overview of cone beam CT (CBCT) and MV portal imaging technology DrPhilEvans,ProfessorofMedicalRadiationImaging,UniversityofSurrey

10:15 Image guidance in radiotherapy: accuracy, frequency, dose, justification DrEllenDonovan,NIHRCareerDevelopmentFellow, TheRoyalMarsdenNHSFoundationTrust

10:45 Refreshments

11:15 Clinical governance in on-treatment imaging MrsÚnaFindlay,SeniorClinicalRadiotherapyOfficer,PublicHealthEngland

11:45 Image guided radiotherapy (IGRT) in clinical practice DrAngelaBaker,LeadResearchandDevelopmentRadiographer, TheClatterbridgeCancerCentre

12:15 Optimisation of cone beam CT (CBCT): balancing dose and image quality DrAndrewReilly,HeadofRadiotherapyPhysics, WesternHealthandSocialCareTrust

12:45 Lunch

13:45 Dose optimisation for soft tissue matching using a Likert scale DrKeithLangmack,HeadofRadiotherapyPhysics, NottinghamUniversitiesNHSTrust

14:15 Extraction of motion data from MOSAIQ MrWayneLomax,ProductManager,ImagingandMotionManagement, Elekta

14:30 Extraction of motion data from ARIA DrAndrewReilly,HeadofRadiotherapyPhysics, WesternHealthandSocialCareTrust

14:45 Refreshments

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15:15 Margin calculations in the context of daily online IGRT MrSamTudor,HeadofQualityControlandDosimetry, UniversityHospitalsBirminghamNHSFoundationTrust

15:45 IGRT and radiographer education MrMarkCollins,SeniorLecturerinRadiotherapyandOncology, SheffieldHallam University

16:25 Questions

16:45 Close of event

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Speaker profiles

Dr Angela BakerLead Research and Development Radiographer, The Clatterbridge Cancer Centre

AngelaBakerisLeadResearchandDevelopmentRadiographeratTheClatterbridgeCancerCentre,ChairoftheIGRTsubgroupofRTTQAandSecretaryfortheUKSABRConsortium.Herdepartmentalroleincludesresponsibilityforleadingthedevelopmentandimplementationofnewtechnologies.ThisincludesIMRT/VMAT,IGRT,4D-CT,SABRandgatingtechniques.AngelaiscurrentlyrunninganumberofdevelopmentalprotocolsatClatterbridgeusing4D-CBCTand6degreesoffreedom(DoF)couchtoimprovetreatmentaccuracy.

Mr Mark CollinsSenior Lecturer in Radiotherapy and Oncology, Sheffield Hallam University

MarkCollinsisaSeniorLectureratSheffieldHallamUniversity.Heisactivelyinvolvedintheteachinganddevelopmentofthesyllabusaroundimagingandtreatmentplanning.Hiscurrentresearchinterestsarerelatedtodecisionmakingin3D-CBCTaswellassupervisinganumberofundergraduateandpost-graduateresearchprojects.OutsideofworkheisDadtotwoyoungchildrenandakeencyclist.

Dr Keith LangmackHead of Radiotherapy Physics, Nottingham Universities NHS Trust

AftergraduationwithadoctorateinmolecularbiophysicsfromOxford,KeithjoinedtheRadiotherapyPhysicsTeamatAddenbrooke’sHospitalinCambridge.Hespentover10yearstheredevelopingspecificinterestsinbrachytherapyandimaging.AfterabriefspellinLincolnasDeputyHeadofRadiotherapyPhysicshemovedtoNottinghamin2002,wherehehasbeenthereeversince.Hiscurrentinterestsareimagingandimprovingtheefficiencyoftheradiotherapyprocess.

Dr Ellen DonovanNIHR Career Development Fellow, The Royal Marsden NHS Foundation Trust

EllenDonovanhasworkedasaClinicalPhysicistinradiotherapysince1992,firstlyatRaigmoreHospitalinInverness,andsince1995,attheRoyalMarsdenHospital,Sutton.From2002shewasPrincipalClinicalPhysicistwithresponsibilityforradiotherapytreatmentunitqualityassuranceandtechniquedevelopment.From1999to2004sheundertookapart-timePhDthatinvestigatedintensitymodulated

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radiotherapyforthetreatmentofearlystagebreastcancer.InSeptember2010shestartedanNIHR/CSOPostDoctoralFellowshipundertheHealthcareScientistsawardscheme.ThiswasfollowedbyanNIHRCareerDevelopmentFellowshipawardthatstartedinJanuary2014.

Dr Phil EvansProfessor of Medical Radiation Imaging, University of Surrey

PhilEvanshasaresearchinterestintheapplicationofphysicsandengineeringtomedicalimaging,particularlywithapplicationtoplanningradiotherapyandmaximisingitsaccuracyofdelivery.PhiljoinedTheCentreforVisionSpeechandSignalProcessing(CVSSP)inJune2012asProfessorofMedicalRadiationImagingandwithakeeninterestinapplyingimagevisionandanalysismethodstotheseimportantmedicalimagingproblems.

PhilhasaBScinPhysicsfromAstonUniversityandaDPhilinPhysicsfromTheQueen’sCollegeandtheNuclearPhysicsLaboratoryinOxford.PhilthenjoinedTheJointPhysicsDepartmentofTheInstituteofCancerResearchandRoyalMarsdenHospitalandthenledateamthereforsomeyearsworkingonimagingresearchinradiotherapybeforejoiningCVSSP.

Mrs Úna FindlaySenior Clinical Radiotherapy Officer, Public Health England

AsRadiotherapyLeadatPublicHealthEnglandÚna’sroleistoassistandsupportarangeoforganisations,includingclinicaldepartments,inaddressingradiationprotectionissuesthatmayaffectradiologicalpracticeandpatientsafety.Thisinvolvestheanalysisofradiotherapyerrorandnearmissevents(RTE)andpromulgationoflearningacrossthecommunity;theprovisionofindependenton-sitesupporttoindividualdepartments;workingwithprofessionalbodiestoprovideguidanceongoodpractice;theprovisionofsupporttoinspectoratesandDepartmentofHealth,andliaisonwithUKprofessionalbodiesandinternationalorganisations.

ÚnaisthecurrentChairofthePatientSafetyinRadiotherapySteeringGroup(PSRT),whichistaskedwithtakingthekeyrecommendationsofTowardsSaferRadiotherapyforwardandaninvitedmemberoftheRadiotherapyBoard.

Mr Wayne LomaxProduct Manager, Imaging and Motion Management, Elekta

WayneLomaxistheProductManagerforImagingandMotionManagementforELEKTA’ssoftwareproductsandbringswithhimanextensivewealthofclinical

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experience.WaynehasbeenatELEKTAforover5yearswherehestartedasaClinicalProductSpecialistgivingdirectclinicalinputtotheR&Dprojectsforimaging.HethenprogressedtobecometheImagingProductSpecialistandProductManagerwithinELEKTAdrivingforwardcommercialproductreleasessuchasXVI,iView,MOSAIQandjointdevelopmentofaCTonRailssystemwithToshibaMedicalinJapan.HavingtrainedasaRadiationTherapistinoneoftheUK’sandEurope’sleadingcentresandworkedatnumerouscentreswithintheUK,Waynehasquicklyestablishedhimselfwithinhisprofession.Hisstrongtechnicalability,forwardthinkingandpassionforbringingvaluetoELEKTA’susers,keepsELEKTAattheleadingedgeofimageguidedradiotherapy,bothindevelopmentandpractice.

Dr Andrew ReillyHead of Radiotherapy Physics, Western Health and Social Care Trust

AndrewReillyisHeadofRadiotherapyPhysicsatAltnagelvinHospital,Londonderry.Throughouthiscareerhehassupportedtheclinicaluseanddevelopmentofradiotherapyimagingtechnologiesandworkedtowardsimprovedsystemsintegration.Hehasaparticularinterestinbridgingthegapbetweendifferentimagingdisciplinesandoptimisingimagingacrosstheradiotherapyprocess.HeisfounderoftheIQWorksproject,leadstheRadiotherapyImagingUserGroupandprovidedphysicssupportunderthenationalNRIGmentoringprogrammeforIGRTimplementation.AndrewservedasChairmanoftheBIRRadiationPhysicsandDosimetryCommitteeuntil2009,wasamemberofBIRCouncilfrom2010to2013,representstheBIRontheDHMedicalPhysicsExpertworkinggroupandcurrentlychairstheBIRInformaticsandClinicalIntelligenceSpecialInterestGroup(SIG).

Mr Sam TudorHead of Quality Control and Dosimetry, University Hospitals Birmingham NHS Foundation Trust

SamTudorisHeadofQCandDosimetryatUniversityHospitalsBirmingham.Hehasinterestsintheuseofradiobiologicalmodellingtoinformtheeffectofgeometricuncertaintiesandimagingstrategies,aswellasthedosimetryofcomplex,smallorunflattenedbeams.Heiscurrentlystudyingforapart-timePhDintheeffectofgeometricuncertaintiesontreatmentsuccess.

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Abstracts

Overview of cone beam CT (CBCT) and MV portal imaging technologyDr Phil Evans

Modernradiotherapyusesimageguidancetotargetthetreatmentaccuratelytothetargetavoidingnormaltissueasefficientlyaspossible.Thispresentationwillcommentonsomeofthecommonlyusedtechniquesforimaginginimageguidedradiotherapy(IGRT).

Severaltechniquesexistandthereiscurrentlynoclearevidencethatasingleoneisbesttouseinallcircumstances.ThemethodstobediscussedincludekilovoltageconebeamCT(ElektaandVarian),megavoltageCT(bothconebeamandslicefromSiemensandTomotherapy),planarimaging(bothkVradiographyandMVportalimaging)andnewerimplementationsoftheseapproachesincludingthecyberknifeandbrainlabmarkerbasedtrackingsystemsandtheverogimballedheadsystem.Competingtechnologiesincludeultrasoundforsofttissuevisualisation,thecalypso,implantedelectromagnetictransponderapproachandtheMRtreatmentunit.

Thecharacteristicsofthesekeysystemswillbepresentedandcomparedwithadiscussionoftheprosandconsofthevariousapproaches.Inadditionthecombinationofmethodswillbediscussed.Thiswillinclude,astheprimaryexample,thecombinationofkVX-raywithopticalsystemsfortrackingmotion.ThedosesdeliveredbytheX-raybasedsystemswillbediscussed,bothintermsoftheoreticalconsiderationsanddosedemonstratedbyavailablesystems.

Learningoutcomes:• Understandingofthecurrentstateoftheartforradiotherapyimagingtechnology• Understandingoftheprosandconsoftheavailableradiotherapyimagingsystems• Understandingofdoseconsiderationsinradiotherapyimaging• Understandingofsomeoftheoutstandingchallengesinradiotherapyimaging• Understandingofthenon-ionisingradiationapproachestoradiotherapyimaging

Image guidance in radiotherapy: accuracy, frequency, dose, justificationDr Ellen Donovan

Background:Imageguidanceisacrucialpartoftheradiotherapychainandisintegratedwithinhighqualityradiotherapytreatment.Itistheroleofimageguidanceinensuringhighlyaccurateandpreciseradiotherapytreatmentthatprovidesitsjustification.ThispresentationisbasedonthedefinitiongivenintheNationalRadiotherapyImplementationGroupReport2012[1]thatstates“ImageguidedRadiotherapy(IGRT)isanyimagingatpre-treatmentordelivery…thatimprovesorverifiestheaccuracyofradiotherapy”.

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Imageguidedradiotherapyprotocols:AppropriatemodificationsshouldbemadetothestandardimagingprotocolssetuponIGRTequipmentwhenitisinstalled.Theseshouldfocusonprovidingtheimagequalitynecessarytoachieveanaccurateradiotherapydelivery.Appropriateuseofverificationprotocolsisgoodpractice,andcanreducetheimagingdosecomponentoftotalorgandose,ifthisisofconcern.

Impactofimageguidance:Twostudies(Hawkinsetal[2]Donovanetal[3])areusedtodemonstrateaquantificationofthebenefitofIGRT.

Educationandlearningoutcomes:• Appreciationoftheimportantofimageguidanceinradiotherapyandits

justificationasanintegralcomponentofaradiotherapyepisode• Understandingoftherelativecontributionofradiotherapyandimagingdose

tototalorgandose• Useofstandardverificationprotocolstobalancetheaccuracy,frequencyand

doseofon-treatmentimaging

Keyreferences:1. NationalRadiotherapyImplementationGroup.Image Guided Radiotherapy

(IGRT) Guidance for implementation and use; 20122. Hawkins,MA,Brooks,C,Hansen,VN,Aitken,A,Tait,DM.Conebeam

computedtomography-derivedadaptiveradiotherapyforradicaltreatmentofesophagealcancer.Int J Radiat Oncol Biol Phys 2010;77:378–383.

3. DonovanEM,BrooksC,MitchellRA,MukeshM,ColesCE,EvansPMetal.TheEffectofImageGuidanceonDoseDistributionsinBreastBoostRadiotherapy.Clin. Oncol2014;26(11);671–676

Clinical governance in on-treatment imagingMrs Úna Findlay

Theclinicaluseofimageguidedradiotherapyhasincreasedrapidlyinthelastfewyears.PortalimagingisbeingsupersededbyconebeamCT(CBCT)inanumberofsites.Howeverthereareon-goingdebatesaroundimagingfrequency,dosemeasurementandmargincalculations.Theimportanceofsafelymanagingtheassociateddoseburdenforthepatientshouldalsobecarefullyconsidered.

ClinicalgovernancehasbeendefinedasaframeworkthroughwhichNHSorganisationsareaccountableforcontinuallyimprovingthequalityoftheirservicesandsafeguardinghighstandardsofcarebycreatinganenvironmentinwhichexcellenceinclinicalcarewillflourish.TheIonisingRadiation(MedicalExposure)Regulations(IR(ME)R)islegislationintendedtoprotectthepatientfromthehazardsassociatedwithionisingradiationintheUK.

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ThispresentationwillreviewtheroleofclinicalgovernanceandtheimplicationsoftheIR(ME)Rinconcomitantimagingprocessesinradiotherapywithafocusonthejustificationandoptimisationoftheseexposures.

Keyreference:ScallyGandDonaldsonLJ.ClinicalgovernanceandthedriveforqualityimprovementinthenewNHSinEngland.British Medical Journal1998;317 (7150),61-65.

Image guided radiotherapy (IGRT) in clinical practiceDr Angela Baker

Followingthepublicationofnationalguidelines,imageguidedradiotherapyhasbeenwidelyimplementedacrosstheUKandIGRTisbeingusedthroughoutthetreatmentprocess.ThecurrentstatusofIGRTintheUKwillbediscussedandclinicalcasespresentedwherethetechnologyisbeingutilisedwithconsiderationofsitespecific,individualisedprotocols.Theroleofclinicaltrialsintheevaluationandimplementationofimageguidedradiotherapywillbedescribedtogetherwithtrainingimplicationsofthetechnology.Theadventofimageguidancetechniquesprovidesopportunitiesandchallengeswithinthedepartmentbutalsomanyopportunitiesforrolechanges.Thepresentationwillfinishdiscussingtheroleofadaptiveradiotherapyandfuturetechnologies.

Educationalaims:• ToconsideradvancedIGRTandadaptiveprocessesandtheirimpacton

departmentalroles

Learningoutcomes:• Todemonstratetheabilitytocriticallyevaluatesitespecificimageguided

techniques• Todemonstrateknowledgeofthetypesofadaptivetechniquescurrently

available• Toconsidertheimpactofchangingroleswithinthemulti-professionalteam

Optimisation of cone beam CT (CBCT): balancing dose and image qualityDr Andrew Reilly

CBCTatthepointoftreatmentdeliveryisnowwidelyaccessibleanditsadoptionhasincreaseddramaticallysincethepublicationoftheNRIGreportonimplementingIGRTanditssupportingmentoringprogramme.AlthoughCBCTundoubtedlymakesmoreinformationavailableaboutpatientsetupthaneverbefore,itisalsothetreatmentimagingmodalitywiththehighestpatientdose

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burden.CaremustthereforebeexercisedwhenusingCBCTfordailyimaging.Optimisationinvolvesbalancingcompetingfactors:ensuringimagesacquiredaresuitablefortheclinicaltaskwhilstminimisingtheburdentothepatient.

Methodsforobjectivelyevaluatingclinicalimagequalityareexplored,includinglinking“physics”measurementsonphantomsbacktotheclinicaltask.Theimportanceofthehumanobserverisemphasised.

Thereissignificantdebatewithintheradiotherapycommunityregardingthemeasurement,quantificationandmanagementofconcomitantdosefromimaging.Apragmaticapproachtothisissuggestedbybuildingonexperiencefromclinicaltrialsandharnessingdataautomaticallycollectedthroughroutineworkflowactivities.Thepotentialroleofimagingdosereferencelevelsisconsideredandthedevelopmentofpeersupportnetworksissuggested,encouragingcancercentreswithsimilarequipmentandcase-loadstoshareprotocolsandexperiences.

Balancingtherelativeimportanceofthevarioustasksacrosstheradiotherapyprocessisanimportantelementofoptimisationinradiotherapyimaging.OpportunitiesfordevelopingrobustCBCToptimisationstrategiesthroughclosemulti-disciplinaryworkingandbuildingrelationshipswithpeersindiagnosticimagingareconsidered.

Avarietyofreal-worldclinicalexamplesisusedtoillustratethechallengesandopportunitiesdiscussedthroughoutthepresentation.

Dose optimisation for soft tissue matching using a Likert scaleDr Keith Langmack

Thepresentationwillstartwithadiscussionofclinicalimagequality.Imagequalityisacomplexmeasureasithasanumberofdifferentaspectstoit.Itispossibletoidentifyfourdimensionsofimagequality:physical(e.g.DQE);psycho-physical(responsetovisualstimuli);observerperformance;anddiagnosticperformance.Inverificationimagingwearenotcarryingoutadiagnosis,however,wecouldreplacethiswith“matchingperformance”.Forthisstudywedefinedimagequalityinrelationtothespecificmatchingtask(softtissuematching)suchthattheimagecarriedenoughinformationtoallowadecision(matching)tobemadewithanacceptabledegreeofcertainty.

Theremainderofthepresentationwilldescribethestudy.TheNottinghamVAMTprostateprotocolrequiresdailyCBCTimagingpriortotreatment.Attheintroductionofthistypeofimagingweusedthemanufacturersuppliedpre-sets.Thesewerefoundtogiveadequateimagequalityforsofttissuematching.Oncewehadbecomeconfidentwiththisprocedure,weinvestigatediftheimagingdosecouldbereducedwhistmaintainingadequateimagequality.Phantom

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studieswiththecatphanandCRISvisiblehumanpelvisphantomindicatedthatitmightbepossibletoreducetheimagingdosebyasmuchas33%.However,patientsarefarmorevariablethanphantoms,sowedecidedtocarryoutaserviceimprovementstudywithacohortofaround20patients.

Forthisstudyweset-upthreedoselevelpre-setswithinourXVI/Mosaiqsystem—fulldose,80%doseand63%dose.TomeasureimagequalitywesetupafourpointLikertscale(excellent,noartefacts;good,fewartefacts;poor,justabletomatch;unsatisfactory,notabletomatch).Thiswasdiscussedwiththeradiographerson-setwhowouldbedoingthematchingsothattheyunderstoodwhatwasrequired.Thestudyprotocolrequiredthetreatmentradiographerstoassessandrecordimagequalityonadailybasis.Forthefirst12fractionsthe“100%dose”pre-setwasused.Forthenext12fractionsthe“80%dose”protocolwasusedwiththeprovisothatiftheimagequalityprovedunsatisfactorythentheywereabletoreverttothepreviousdoselevel.Forthefinalfractionsthe“63%dose”protocolwasused,againwithaboveproviso.

ThedatawasanalysedwiththeFreidmantestfollowedbytheWilcoxonsignedranktestwithBonferroniadjustmentforrepletion.Thisanalysiswillbeexplainedinthepresentation.Theresultsofthestudyshowedthatwecouldusethe“80%dose”protocolforallpatients,withthe“63%dose”protocolforpatientswithalateralseparationlessthan35cm.Thishasnowbeenclinicallyimplementedwithnoreportedissues.WeaimtorepeatthisstudyforotherbodysiteswhereweroutinelyuseCBCTimaging.

Extraction of motion data from MOSAIQMr Wayne Lomax

ELEKTA’sMOSAIQOncologyInformationSystemhasawealthofdataandknowledgerelatingtonotonlythepatientanditscarepathbutalsoyourradiotherapyandoncologydepartments.OnesuchdataMOSAIQisabletorecordfromnumerousvendorsviaspatialregistrationobjects,registeringimageswithinMOSAIQorgeneralmanualrecordingisoffsetdatafromdailyIGRT.

DuringthissessionweintendtocoverhowtoextractdailyIGRToffsetdataforapatientbygeneralreportingincludedinMOSAIQforuseoutsideoftheMOSAIQenvironment.WewillalsocoverwhereandhowyoucangethelporlearnhowtocreatecustommorecomplexreportsfromyourMOSAIQdata.DuringthesessionwewillalsotouchonsomeotherareaswithintheELEKTAIGRTproductswheredatacanbeextractedrelatingto4Dmotiondata.ThesessionwillalsogiveaglimpseintothefuturevisionofELEKTAsoftwareandinformationguidedcancercare.

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Extraction of motion data from ARIADr Andrew Reilly

ARIAasanoncologymanagementsystem(OMS)isunderpinnedbyadatabasethattrackseveryaspectofthetreatmentdeliveryprocess.Thisincludessetupverificationimaging,detailsoftheimagematchingprocess,respiratorymotionwaveformsandcouchpositionsduringimagingandtreatment.Additionalinformationsuchasthetimingsofdifferenteventsandtheoperatortakingresponsibilityforthetreatmentarealsorecorded.

ThispresentationdescribestheextractionofdatafromARIAtocharacteriseinter-andintra-fractionmotion.Thedatacanbeutilisedtocalculaterandomandsystematicsetuperrors,whichinturnmayfeedintomargincalculationsusingthealgorithmsintheRCR“OnTarget”reportorotherpatientsetupmodelspublishedintheliterature.Evaluatingrespiratorywaveforminformationovertimeenableschangesinbreathingmotiontobeidentifiedandfacilitatesinvestigationofpotentialsynchronisationissuesbetweenthemovementofinternalanatomyandthatoftheexternalsurrogate.

Anumberofdataextractionmethodsareconsidered,allsuitedtodifferentoperationalconditionsyetallyieldingthesameoutputdata.Theseincludeusingtoolsbuilt-intotheARIAuserinterface,advancedARIAreporting,ARIAscriptingandARIAanalytics.

AlthoughtheNRIGreportonimplementingIGRTencouragestheroutinemonitoringandanalysisofsetuperrorsthishasnotyetbeenfullyrealisednationwide.Apotentialcommunityinitiativeissuggestedasameansofachievingthis.

Margin calculations in the context of daily online IGRTMr Sam Tudor

IntheabsenceofIGRT,andtosomeextentwhereIGRTtechniquesareperformedlessfrequentyandoff-line,thereexistsignificantsourcesoftranslationalgeometricinaccuracy,includingsetuperroranddailyinternalmotionofthetargetwithinthepatient.Thesesourcesoferrorare,however,typicallyeasytomeasureandincorporateintoaCTV-PTVmarginformulaesuchasthevanHerkformula(BIR2003[1],vanHerketal.[2]).Theincorporationofothercomponents,includingrotationalerror,intrafractionalmotionanddelineationerror,intothevanHerkmethodologyposessomeproblems,butwhenthesecomponentsweredeterminedtoberelativelysmall,theexactmethodoftheirconsiderationhadlittleimpactonthecalculationofthetotalCTV-PTVmargin.

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However,inthecontextofdaily,onlineIGRT,thelargerandmoreeasilyconsideredcomponentsofuncertaintyarethefirsttodisappear.LessscrutablecomponentssuchasrotationalerrorandintrafractionalmotionarelesslikelytobecorrectedbytheIGRTsystem,andtheyarejoinedbyanadditionalcomponentofregistrationerrorthatcanbesimilarlydifficulttoconsiderhowtomeasureandacton.

ThispresentationdiscussessomeofthefeaturesofresidualcomponentsofuncertaintythattypicallyremainaftertheintroductionofdailyonlineIGRT,andpresentstechniquestoincorporatesomeoftheseintoconventionalmarginformulae.

AbriefdiscussionofmarginformulaebasedonradiobiologicalmodellingwillfollowtogetherwithconsiderationoftheirworthinlightofthelimitedpublishedclinicalevidenceofmarginreductionwithIGRT.

Keyreferences:1. BIR.PreparedbyaWorkingPartyoftheBritishInstituteofRadiology.

Geometricuncertaintiesinradiotherapy:definingtheplanningtargetvolume.London,UK:2003.(ISBN0-905749-53-7).

2. VanHerkM,RemeijerP,RaschCandLebesqueJ.V.Theprobabilityofcorrecttargetdosage:dose-populationhistogramsforderivingtreatmentmarginsinradiotherapy. Int. J. Radiat. Biol. Phys.2000;47 (4),1121-1135.

IGRT and radiographer educationMr Mark Collins

Theroutineimplementationof3Dimagingduringtreatmentverificationhasbeenoneofthelargestchangesinradiotherapypracticeinthelast10years.Thespeedatwhichthistechnologyhasbeenimplementedhasraisedanumberofissuesfortheradiotherapycommunityandtheprofessionalsinvolvedintheeducationoftheworkforce.

HigherEducationInstitutions(HEIs)playalargeroleinthetrainingoftherapyradiographers.TheultimategoaloftheHEIistotraingraduatesthatarefitforpurposeinthemodernradiotherapydepartment.ItisessentialthatHEI’sdeveloptheircurriculumandadaptmethodsofdeliverytokeeppacewiththeimplementationofthistechnology.

Thereareanumberofquestionsandchallengesthatmustbeovercomebeforethiscanhappen.Therapyradiographerstypicallyspendaround50%oftheirtraininginaclinicaldepartmentand50%inacademia.AtSheffieldHallamUniversity(SHU),studentsarebasedatonesiteforallclinicalpracticewiththeexceptionofa3weekelectiveplacement.Thisallowsstudentstobecomefamiliar

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withtheprotocolsandpracticesatthissite,aswellasgivingthemtheskillsandexperiencetheyneedtoworkinthewiderradiotherapycommunity.Asaresultofthismethod,studentsareexposedtoworkingpracticesincludingradiotherapytreatmenttechniquesandIGRTpracticeinoneplacementenvironment.

AnumberofstudieshavedemonstratedthatIGRTpracticevariessignificantlyacrosstheUK.ThesestudiesreflecttheexperiencesofstudentsatSHU,withstudentsreportingverymixedexperiencesofIGRTtrainingwhilstonplacement.Aswithotheraspectsoftheundergraduatesyllabus,IGRTtrainingshouldideallybedeliveredinpartnershipwiththeHEIandclinicaldepartmentsbothtakinganactiverole.Attimes,theimplementationofthiscanbeproblematicduetoanumberofconstraints.Theseincludetheavailabilityofthetechnologyinsomeclinicalsitesaswellasstaffingresourcesandvaryinginter-departmentalstaffingstructuresforimagereview.

ThequestionofwhatlevelofIGRTskillsandcompetencesarerequiredofnewgraduatesremainsunanswered,andasaprofessionweneedtoworktowardsdefiningcommoncompetencies.Overthelast2years,SHUhassignificantlydevelopeditsIGRTteachingsyllabus.Inthesecondandthirdyearsoftheirtraining,studentscarryoutanumberofpracticalsessionsusingcasestudiesonVarianAria.Thesehavebeenwellreceivedbystudents,butacommonthemeofthefeedbackisthatstudentswouldlikemoretimeforthesesessions.

SHUisworkingcloselywithitslocalclinicaldepartmentstotrainitsgraduatestohavetheskillsandcompetenciestheyneed.TheywillbeconductinganationalsurveyinlatespringtogainawiderperspectiveonundergraduateIGRTtraining.

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FORTHCOMING EVENTS

MANAGEMENT AND RADIOLOGY—A GUIDE TO CURRENT AND FUTURE MANAGEMENT ISSUES IN RADIOLOGY

1 MAY 2015LONDON

AN EVENING WITH PROFESSOR LÁSZLÓ TABÁR:A NEW ERA IN THE DIAGNOSIS AND TREATMENT OF BREAST CANCER

11 MAY 2015LONDON

THORACIC IMAGING15 MAY 2015CAMBRIDGE

IMAGING IN DEMENTIA18 MAY 2015

LONDON

EMERGENCY OUT OF HOURS RADIOLOGY20 MAY 2015

GLASGOW

NEURORADIOLOGY UPDATE AND REFRESHER COURSE18–19 JUNE 2015

LONDON

WESSEX BRANCH SUMMER EVENT19 JUNE 2015CHICHESTER

FUNCTIONAL IMAGING IN RADIOTHERAPY10 JULY 2015

LONDON

IRMER UPDATE 28 SEPTEMBER 2015

BIRMINGHAM

UPDATE ON IMAGING NON-ACCIDENTAL INJURY2 OCTOBER 2015

LONDON

HOW TO GET INTO RADIOLOGY AND RADIOLOGY SUBSPECIALTY CAREERS DAY 8–9 OCTOBER 2015

MANCHESTER

OPTIMISATION IN DIGITAL RADIOGRPAHY9 OCTOBER 2015

LONDON

LIVER IMAGING12 OCTOBER 2015

LONDON

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