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Treatment workflow – hospital expert perspective

Treatment workflow – hospital expert perspective. Harald Hentschel EBG MedAustron. Introduction Historical overview of MedAustron Medical staff groups Patient referral Comparison of photon and ion beam radiotherapy Beamgeneration and - application

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Treatment workflow – hospital expert perspective

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  1. Treatment workflow – hospital expert perspective Harald Hentschel EBG MedAustron <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  2. Introduction • Historical overviewof MedAustron • Medical staffgroups • Patient referral • Comparisonofphotonandion beam radiotherapy • Beamgenerationand -application • Immobilization/simulationandimaging • Treatment planning • Irradiation • Challenges in (ion beam) radiotherapy • Ramp-upandimprovements • Further development topics <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  3. 1. introduction a. Historical overviewof MedAustron History End of 1980s 1st drafts and proposals – exclusively designed for research 2005 Decision to realize the project with a modified objective: “therapy & research” 2012 Building completion 2013 Start of the accelerator installation November 2014 The 1st proton beam is measured in a treatment room December 2016Start of patient treatment in 1 room August 2017 Start of the 2nd room (horizontal only) June 2018 Activation of vertical beam line in the 2nd room <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  4. 1. introduction b. Medical staffgroups at MedAustron Radiation Oncologist Case preparation, evaluation of eligibility for ion beam radiotherapy, evaluation and considerations of prior treatments Patient education Definition of target volumes Evaluation of treatment plan and approval Physical examinations during therapy and follow-up Contact person for referring physicians Patient administration (Reception, Intake) Administration of patient data, creation of medical record, import and export of imaging data Point of contact for patients during their treatment session Communication of appointments Communication and exchange of data between MedAustron and referring institutions <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  5. 1. introduction b. Medical staffgroups at MedAustron Clinical Studies Every patient (who agrees) is included in a study protocol Initial Check to acquire baseline data for comparison + interviews during and at end of therapy Creation of valuable data for the assessment of ion beam treatment outcome Patient care – Nurses Patient education about skin care, nutritional support Treatment of therapy related side effects Blood sampling Drug administration (e.g. anxiolytics) Coordination of external anesthesia team Patient care - Patient Care Coordinator - Supports patients prior to and during therapy (accommodation, transport, recreational activities, general counseling) <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  6. 1. introduction b. Medical staffgroups at MedAustron Radiotherapy Technologists (radiographer, radiology technologist, ...) Patient education Creation of immobilization using positioning devices Imaging (CT, MR, PET-CT) Registration/Fusion of imaging data Organ at risk delineation Treatment planning together with MPE Preparation of treatment sequence (Treatment Operation) DryRuns in the treatment room together with MPE Scheduling Patient-positioning and radiological positioning-verification Patient and treatment surveillance during treatment Support of the patient <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  7. 1. introduction b. Medical staffgroups at MedAustron <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  8. 2. Referralprocedure Catalog with indications that are accepted by the main association of Austrian social insurances Costs are covered if a Tumorboardrecommendationis available (Tumorboard = committee of oncological specialists of the referring hospital) If a case is not included in the catalog – Insurance may cover the costs Administrative workflow of filing the case at the insurance is done by MedAustron Contracts with some international health insurances are in place Alternatively, patients may cover the treatment costs by themselves <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  9. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Electron/photon-LINAC vs. p, C Synchrotron 50t 7.5 m 2.5 m 100 m <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  10. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Electron / photon-LINAC vs. p, C Synchrotron • Simultaneousoperationofall availabledevices • Treatment roomssharethe beam • Simultaneous beam deliveryisnotpossible • Sequentialandoverlappingoperation <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  11. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Unit consistingof- Positioningdevice/couch • - X-rayimaging- Radiation source •  Designedforisocentric • treatment • Veryshortcouchmovementduringtreatment • Patientpositioningand –verificationsystem (Imaging Ring) • Beam outlet (nozzle) • Designedfor non-isocentrictreatment • Several time consumingcouchmovementsduringtreatment Image courtesy: Varian Medical Systems, Elekta Instrument AB <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  12. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Ideal case Pat. 3 Pat. 1 Beam Exit Init Pos+Img IR 2 Beam Exit Init Pos+Img Beam IR 3 Init Beam Exit Pos+Img Init Pos+Img Pat. 4 Pat. 2 Pos+Img Patient-Enter, Positioning, X-Ray Imaging (planarorConeBeamCT), Verification/Image Registratin Includesseveral Robot- und ImagingRingMovements : 9 – 14 min Init Beam-release room1, beam-occupation room2, initializationoftheaccelerator: 2 -3 min Beam Mainly 2 beamsfrom different directions. Includesrobotmovementsbetweenthebeamsandinitializationoftheaccelerator : 12 – 15min, pure beam-on time 10 – 13 min (rangeof 5-50minutes) Exit Optional exit-imaging fortheassessmentofintrafractionalpatient- ororganmotion. Robotmovementtothestep on/off position. Release, mobilizethepatient. Patient leavestheroom.

  13. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Technical problemsduring beam applicationaffect ALL rooms Beam Exit Init Pos+Img IR 2 (Plan) Beam Exit Init Pos+Img Pos+Img Pos Beam Exit Init IR 2 (Real) Beam Exit Init Pos+Img Beam Beam Exit IR 3 Init Pos+Img • Problems duringpatientsetup, patientmovement, etc.: waiting time in theotherroom(s) Beam Beam Exit Init Pos+Img .......... Init Pos+Img IR 2 Init Pos+Img Beam Exit Init Beam Exit Pos+Img IR 3

  14. 3. Comparisonphotonandion beam radiotherapy a. Beamgenerationand -application • Downtime ofonetreatmentroom, e.gImagingRingor Robot:  Inefficient beam utilization out oforder IR 2 Beam Exit Init Pos+Img Beam Exit Init Pos+Img Beam Init Pos+Img Pos+Img Init Beam Exit Pos+Img Exit Beam Init IR 3 • Long beam-time at bigtargetvolumes: waiting time in otherroom(s) Beam IR 2 Beam ........... Exit Init Pos+Img Init Pos+Img Pos+Img Beam Exit IR 3 Init Init Beam Exit Pos+Img

  15. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • Basic requirementsarethe same forphotonsandions- reproducible- minimizepatientmotion- reduceorganmotion-comfortable- stable- unobstructed beam path • Considerationof- treatmentduration (25-60min)- No material in the beam entranceregionunlessitcannotbeavoided (mask) oron purpose (bolus, flab) • Immob.systemswhichallowfor a minimal Air-Gap- Majorityofthesystemsarestandard (photondevices)- somespecialized, ion-specificproducts • Exclusivelyindexedpositioning <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  16. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • Immobilizationdevices <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  17. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • BoS (Base of Skull Overlay)- Treatment in thehead & neck region- Minimal distance (=airgap)betweenpatientandnozzleImprovementof beam geometry <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  18. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • „Alternative“ positionstocompensatefor limited beam entranceanglesTiltingandrotationofthehead • Decubitus position - Problematic, but canbedonewithtrainingandexperience - requirescreativity - dependant on patient´sdiseaseandphysicalcondition - nostandardsavailable; havetobeestablished <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  19. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • Planning-CT withpredefinedprotocols(X-rayandgeometricparameters) • MR in immobilizedposition (ifpossible)- incl. positioningdevices • CT mostly w/o contrast. MR alwayswithcontrast, unlessthereis a contraindication(renal function, knownallergyorintolerance) • Immobilizationandimagingarepre-discussedwithmedicalphysicistandtheradiationoncologist. <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  20. 3. Comparisonofphotonandion beam radiotherapy b. Immobilization/Simulation and Imaging • Definition and 3Dsimulationofthepatientensetup Collisionavoidance <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  21. 3. Comparisonofphotonandion beam radiotherapy c. Treatment planning Involved staff: Medical physicists, RTTs and Radiation Oncologists • Import of Planning-CT and MR imaging to the treatment planning system • Import of external images • Registration/Fusion of images • Contouring/segmentation of OARs • Dose-prescription and contouring of the target volumes by the radiation oncologist • Planning <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  22. 3. Comparisonofphotonandion beam radiotherapy c. Treatment planning • Preparation of QA plans • Plan approval by the responsible RO and the board of ROs • Creation of the Treatment Operation (= predefined sequence of actions) • Physical plan verification by MP • Dry run (w/o patient) in the treatment room • Final plan approval <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  23. 3. Comparisonofphotonandion beam radiotherapy d. Irradiation <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  24. 3. Comparisonofphotonandion beam radiotherapy d. Irradiation - Workflow is supported by a TPS based modelling of: Room-, robot- and patient geometry 17 <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  25. 3. Comparisonofphotonandion beam radiotherapy d. Irradiation • Softwarebased • Nomanualcontrolofthepositioningtable (exception: emergency) • Pre-definition of:- Robot movements- Imaging geometryand - parameters- Registrationparameters- Sequenceofthebeams / portals <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  26. 3. Comparisonofphotonandion beam radiotherapy d. Irradiation • Movement totreatmentposition • Irradiation Image registration: current vs. plannedposition Patient identification, step-on andpositioning X-rayimageacquisition <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  27. 3. Comparisonofphotonandion beam radiotherapy d. Irradiation <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA> 27

  28. 4. Challenges in (IB)RT • ReproducibilityofpositioningThe accuracyofthepositioningiscrucialtoensurecorrect dose delivery.... whichcanbechallenging ... <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  29. 4. Challenges in (IB)RT • ClaustrophobiaMR imagingAlthoughtheoncologyMRI has a relativelywideopening („big-bore“) itis still a narrowtubeIrradiationPatientsareimmobilizedwithtightand rigid maskswhichrestrictanymovementoftheregionofinterest • Long treatment timeDepending on thesizeofthetreatmentvolume, theproceduretakesbetween 25-60 minutes- discomfort- pain due toposition, pressuremarks (getsworseover time !!!)- Coughingandsneazingcausesinterruptionsandrepetitionofworkflowsteps furtherincreaseoftreatment time <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  30. 4. Challenges in (IB)RT • InterruptionsDue tothecomplexityoftheacceleratorandthe MedAustron specificuseof prototype medicaldevices (Robot, ImagingRing, Software) downtimesareusuallylongerthan in conventional RT. • Increasedcomplexity in theanesthesiaworkflowforpediatricpatientspatients must not eatanddrinkpriortosedation durationofsedationis limited • Difficulttimingofpatient-specificroutines- drinkingprotocollfordefinedbladderfilling- enemaforemptyingtherectum- medication • Competingpatientappointments- concomitantexternaltherapy, rehab, examinations <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  31. 5. Rampupandimprovements • Numberofpatients per day <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  32. 5. Rampupandimprovements • Increaseofefficiency • In-room time: Patient-enterto Patient-exit <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  33. 5. Rampupandimprovements • Increaseofefficiency • Positioning andverification: Patient-entertostart 1st beam <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  34. 5. Rampupandimprovements • Increaseofefficiency • Reducenumberofbeams per treatment(splittreatment plan into „beamsets“ whicharetreated in an alternatingsequence • Increaseofrobotspeed • Reducerobottraveldistancesbydefinitionofoptimizedstep-on andimagingpositions • Reductionof beam-time bystepwiseimplementationofacceleratorperformanceincreaseprojects • RTT workflowimprovements • More effectiveand quicker troubleshooting <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  35. 6. Further development • Surface scannerinstallation: C-RAD Catalyst / Sentinel • Patient setup • Surveilance (intrafractionmotion) • 4D CT • Gating Image courtesy: C-RAD <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  36. 6. Further development • Surface scannerinstallation: C-RAD Catalyst / Sentinel • Hardware installationisfinished • Next steps: Gradual installationof SW packages Acceptance Training (MP, RTT, MedTec) 4D CT - clinicaluse Assistedsetup - clinicaluse Intrafractionmotionsurveillance Future goal = gatedirradiation <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  37. 6. Further development • Carbon ions 07/2019 • Proton-Gantry 12/2021 • Numbers oftreatedpatients2018: ~200 patients (avg. 26/d)Goal for 2019: 270 patients (avg. 30/d) • Treatment timesMo-Fr, includingholidaysCurrently 8:10 – 18:00 (in factuntiltreatmentsarefinished)07/2019  8:10 – 19:00 <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA>

  38. Closingremark Interdisciplinarycooperationofteamsisthepreconditionfor- treatmentoptimization- cost-efficiency- effectiveness - safety

  39. Thankyou Questions ? <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA> <DokKlasse: AAnnn><Inhaltskennz.: xxxxx><DokNo: xxxxxxxxxxxxxxxxx><Datum: JJJJ-MM-DD><Version: n.n><Schutzklasse: nur intern><Vertraulichkeit: offen><Eigner: AA> 39

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