Comprehensive Collective Compendium on Advanced Radiotherapy Technology and Medical Protocols

1. Radiotherapy innovative Technology combined with Hospital & Home-Care Standards Medical Protocols and Guidelines: A collective Compendium Spyropoulos B., Adamopoulou M., Arbis S., Bouboukiotis G., Chatziavazis G., Chatzigeorgiadis K., Golfinopoulos K., GolfinopoulouA., Kalfas A., Karatzetzos S., Kavadas D., Kefalidis E., Kotsinonos G., Koukoularis P., Kyriazopoulos C., Linardatos D., Makri S., Marinis M., Monocholias K., Roumeliotis S., Stathopoulos I., Stavridis K., Stergiou T., Tsantoulis M., Tsitsigronis O. Biomedical Engineering Department, Technological Educational Institute (TEI) of Athens, Athens, Greece basile@teiath.gr

2. The aim of this project • A heuristic “3-dimensional” project is presented, accomplished by the 24 post-graduate students, following our Biomedical Engineering Department’s MSc.-Course:“AdvancedBiomedical Technology”. • The project has addressed: • first, Radiotherapy innovative Technology as reflected on Industrial Property published documents; • second, cardinal Patient-care and Medical-managerialaspects of Hospital and Homecare for CA-patients; • and finally, their combination with relevant Medical Protocols, Guidelines & Standards. HNPS 2016 Symposium

3. Methodological approach • Parts of the three modules of the 4th -trimester, i.e. • “Large Therapeutic and Diagnostic Facilities Safety, Radiation Protection and Quality Assurance” (MTMBIT24). • “Biomedical Technology (BMT) of Home-Surveillance, Health-Care Management and Online Health Services” (MTMBIT25). • “BMT-Quality Assurance, Industrial Property Rights, Technical Standards and Medical Protocols and Guidelines” (MTMBIT26). taught by the first author, have been combined. • Each student has prepared and orally presented a “3-D” paper, as indicated in the next Tables. HNPS 2016 Symposium

4. The three modules of the 4th Trimester of the MSc.-Course that “lend themselves” to their combination An excerpt of the Drop-box created to accommodate the assignments HNPS 2016 Symposium

5. The outline of the three major components of the formed Compendium HNPS 2016 Symposium

6. Patents and IP-Documents relevant to RT Systems HNPS 2016 Symposium

7. IMRT Adoption in the United States 1992-2004(Mell et al., 2005) The cumulative adoption of intensity-modulated radiation therapy (IMRT) is illustrated by year (the asterisk indicates data through August 31 2004. HNPS 2016 Symposium

8. Method and device for online IMRT verificationUS 8218725 B2 (Publication date July 10, 2012) HNPS 2016 Symposium

9. Indicative numbers of publishedIP-Docs relevantto Radiotherapy(Spyropoulos et al. 2014) HNPS 2016 Symposium

10. EP2968980 A1-2016-01-20 (1) COMPACT PROTON THERAPY SYSTEM WITH ENERGY SELECTION ONBOARD A ROTATABLE GANTRY • Systems and apparatuses for providing particle beams for radiation therapy with a compact design and suitable to a single treatment room. • The radiation system comprises a stationary cyclotron coupled to a rotating gantry assembly through a beam line assembly. • The system is equipped with a single set of dipole magnets that are installed on the rotating gantry assembly and undertakes the dual functions of beam energy selection and beam deflection. • The energy degrader may be exposed to the air pressure. • The beam line assembly comprises a rotating segment and a stationary segment that are separated from each other through an intermediate segment that is exposed to an ambient pressure. HNPS 2016 Symposium

11. EP2968980 A1-2016-01-20 (2) COMPACT PROTON THERAPY SYSTEM WITH ENERGY SELECTION ONBOARD A ROTATABLE GANTRY HNPS 2016 Symposium

12. EP2968980 A1-2016-01-20 (3) COMPACT PROTON THERAPY SYSTEM WITH ENERGY SELECTION ONBOARD A ROTATABLE GANTRY HNPS 2016 Symposium

13. Oncology patients’ Hospital and Home-Care needed HNPS 2016 Symposium

14. Hyperthermic Intraoperative Intraperitoneal Chemotherapy Safety ConsiderationsWhite et al.http://dx.doi.org/10.1016/S0001-2092(06)63122-0 • Perioperative staff members encounter many occupational exposure hazards in the workplace. • Cytotoxic agent exposure is a relatively new hazard that perioperative staff members are experiencing as more surgeons use hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) to treat patients with abdomino-pelvic cavity malignancies. • Routes of exposure include inhalation, ingestion, injection, and skin contact. • The National Cancer Institute, the Occupational Safety and Health Administration, and the Joint Commission on Accreditation of Healthcare Organizations provide guidelines for the safe administration and handling of cytotoxic agents. • Institutions in which cytotoxic agents are administered should use these guidelines to develop policies, procedures, and educational programs to protect surgical patients and perioperative staff members. AORN J 63 (April 1996) 716–724. HNPS 2016 Symposium

15. Patient Temperatures at Three Anatomic Sites,Heat Exchanger and the In-Flow Line HNPS 2016 Symposium

16. Chemotherapy Safety Precautions Essential Across Practice Settings and in the Home http://nursing.onclive.com/publications/oncology-nurse/2014/may-2014/chemotherapy-safety-precautions-essential-across-practice-settings-and-in-the-home#sthash.rAna506h.dpuf HNPS 2016 Symposium

17. Side effects of Brain-tumour Radiosurgeryhttp://www.cancerresearchuk.org/about-cancer/type/brain-tumour/treatment/radiotherapy/stereotactic-radiotherapy-for-brain-tumours#sfx • There are usually very few immediate side effects from radiosurgery. • A dose of steroids before the treatment, or straight afterwards help to prevent side effects due to swelling of the brain. • The patient may feel sick or faint at first, have a headache or also feel a bit weak and dizzy. • Aftertreatment with a head frame, the patient may have slight bleeding from the points where the frame was attached to skull. • Tingling or itching where the frame was attachedis a normal sign of healing.  • There is a small risk of a seizure after Radiosurgery so driving is not allowed for at least a month afterwards. HNPS 2016 Symposium

18. The example of Varian Trilogy Radiation Therapy System • The Trilogy™ Stereotactic System from Varian Medical Systems is among the most advanced, sophisticated machines of this type. • As a leading image-guided radiotherapy (IGRT) system, it marks the beginning of a new generation of cancer care. • The versatile system combines imaging and treatment technologies, and can be used to deliver the widest range of external beam radiotherapies: • 3-D conformal Radiotherapy. • IMRT. • Stereotactic Radiosurgery. • Fractionated stereotactic Radiation Therapy. • Intensity-modulated Radiosurgery for cancer and neurosurgical treatments. HNPS 2016 Symposium

19. The Varian Trilogy Linear Accelerator Rapid Arc HNPS 2016 Symposium

20. Medical ProtocolsGuidelines and Standards HNPS 2016 Symposium

21. Stereotactic Ablative Body Radiotherapy (SABR)Quality Assurance (I)http://www.ncbi.nlm.nih.gov/pubmed/24399615 Hypofractionated image guided radiotherapy of extracranial targets has become increasingly popular as a treatment modality for inoperable patients with one or more small lesions, often referred to as stereotactic ablative body radiotherapy (SABR). This report details the results of the physical quality assurance (QA) program used for the first 33 lung cancer SABR radiotherapy 3D conformal treatment plans. SABR involves one or few fractions of high radiation dose delivered in many small fields or arcs with tight margins to mobile targets often delivered through heterogeneous media with non-coplanar beams. Patient-specific QA have been conducted, similar to the more common intensity modulated radiotherapy QA with particular reference to motion management. HNPS 2016 Symposium

22. Stereotactic Ablative Body Radiotherapy (SABR)Quality Assurance (II) http://jtd.amegroups.com/article/view/172/html HNPS 2016 Symposium

23. Stereotactic Ablative Body Radiotherapy (SABR)Quality Assurance (III)http://www.ncbi.nlm.nih.gov/pubmed/24399615 Individual patient QA was performed in a Perspex phantom using point dose verification with an ionisation chamber and radiochromic film for verification of the dose distribution both with static and moving detectors to verify motion management strategies. While individual beams could vary by up to 7%, the total dose in the target was found to be within ±2% of the prescribed dose for all 33 plans. Film measurements showed qualitative and quantitative agreement between planned and measured isodose line shapes and dimensions. The QA process highlighted the need to account for couch transmission and demonstrated that the ITV construction was appropriate for the treatment technique used. QA is essential for complex radiotherapy deliveries such as SABR. We found individual patient QA helpful in setting up the technique and understanding potential weaknesses in SABR workflow, thus providing confidence in SABR delivery. HNPS 2016 Symposium

24. IAEA Library Cataloguing in Publication Data www-pub.iaea.org/mtcd/publications/pdf/pub1196_web.pdf www-pub.iaea.org/MTCD/publications/PDF/pub1296_web.pdf HNPS 2016 Symposium

25. Concluding Remarks (1) • We have collectively attempted an interdisciplinary approach in the field of Radiotherapy, based on three pillars: • Radiotherapy innovative Technology as reflected on Industrial Property published documents. • Cardinal Patient-care and Medical-managerial aspects of Hospital- and Home-Care for Oncology patients. • Their combination with relevant Medical Protocols, Guidelines and Technical Standards. • 72 discrete topics have been grouped in 24 “case-vectors” and have been handled successfully by the 24 graduate students that have participated in this rather complicated, however, creative and definitely interesting “examination”. HNPS 2016 Symposium

26. Concluding Remarks (2) • Around 1000 pages of relevant content (over 1 GB) with numerous Figures and Tables are included in the produced Compendium. • The quality of the students’ papers and their oral presentations, corroborate the need of introducing novel, contemporary and creative examination methods, attracting their interest and promoting their self-confidence. • These results were no surprise; since 2007 we employ this method in two Courses taught in the Postgraduate Program "Information Technologies in Medicine and Biology" (I.T.M.B.), organized and administered by: • The Department of Informatics and Telecommunications of the National and Kapodistrian University of Athens (UoA). • The Biomedical Engineering Department of the Technological Educational Institute (TEI) of Athens. • In collaboration with the Foundation for Biomedical Research of the Academy of Athens (BRFAA) and the Institute of Informatics and Telecommunications of the National Centre for Scientific Research "Demokritos". HNPS 2016 Symposium

27. WS 2014-2015 1-D exams approach in BME M.Sc.-Course (2014-2015) in nano-macro IVD HNPS 2016 Symposium

28. Concluding Remarks (3) • These new specific “multidimensional-projects”, have been introduced last year in the new post-graduate Course, “Advanced Systems and Methods in Biomedical Engineering”, inaugurated in December 2014 in our Department. • Most of these postgraduate-students are being employed for several years in various Biomedical Technology Companies and are following the lectures, after their “normal” eight-hours shift. • This fact demands much more effort, to work every semester, on an interdisciplinary project, beyond attending allthe lectures and studying for the other exams of the program. • Therefore, the results so far, corroborate the trust shown to our students, concerning the outcomes of this projects and create an optimistic spirit for their future… HNPS 2016 Symposium

29. SS 2015 collective 3-D examination approach HNPS 2016 Symposium

30. WS 2015-2016 final collective 1-D examinationThe next generation 3-D projects are coming soon… HNPS 2016 Symposium

31. Highlights from the 24 presentations… Thank you for your patience!!! HNPS 2016 Symposium