We were excited to sit down with Andres Huertas, MD, radiation oncologist, and Pierre-Alexandre Rigaud, medical physicist, both from the Radiotherapy Institute for the Sud Oise region in Creil, France. The Institute is part of Amethyst Radiotherapy Group.
Dr. Huertas and Mr. Rigaud discuss with us the value of the latest radiotherapy techniques and technology in the treatment of cancer. The clinic, located within the medical campus of the public hospital Groupe Hospitalier Public du Sud de L’Oise Creil (GHPSO), is equipped with both ExacTrac Dynamic® and ExacTrac Dynamic Surface® systems for patient positioning and monitoring during radiation treatment for cancer. The clinic expanded in 2010 after becoming part of the Amethyst Radiotherapy Group and patients come from all over the region for advanced and comprehensive cancer care.
What is the primary mission of your department at the Radiotherapy Institute?
Dr. Huertas: “Our mission is to provide our patients with the same quality of care they would receive in academic hospitals more than an hour’s drive from our region. In the past five years, we have implemented stereotactic radiotherapy for all organs, deep inspiration breath hold treatments and supportive care treatments. We aim at delivering the highest level of radiotherapy, something usually only available in much larger centers. For this reason, we chose the versatility of the different ExacTrac Dynamic systems to help us meet our needs.”
You have already been using ExacTrac Dynamic on your TrueBeam® linac for over three years. What made you decide to equip your other linac with ExacTrac Dynamic Surface?
Dr. Huertas: “Our first ExacTrac Dynamic system has greatly benefitted our patients presenting with indications that benefit from stereotactic radiosurgery and body radiation therapy. The addition of ExacTrac Dynamic Surface, the new surface-only system by Brainlab, allows us to standardize the department: We are now able perform tattooless prepositioning for all our treatments. Furthermore, we are able to split clinical indications between the two machines depending on patient needs and the type of treatment to be performed.”
Now that you have two ExacTrac Dynamic systems, how do you plan to coordinate the daily clinical routine of the department between the technologies?
Dr. Huertas: “We will continue to perform cranial stereotactic radiosurgery (SRS) by leveraging the unique benefits that ExacTrac Dynamic brings to such treatments, like the X-Ray verification and active correction in six degrees of freedom, even at non-coplanar angles. With the breath hold workflow we have already treated over 200 breast patients and about 100 lung, adrenal gland and some liver cases. For such indications, the automated breath hold gating functionality is crucial as it ensures safe and accurate irradiation that avoids the heart and other critical organs. Our plan for the future is to perform primarily SRS and breath hold treatments on ExacTrac Dynamic and to focus more on thoracic, pelvic and other breath hold cases on ExacTrac Dynamic Surface.”
What do you value most in the new ExacTrac Dynamic Surface breath hold workflow?
Mr. Rigaud: “What we really like about the new workflow is that the software has been designed with the needs of clinicians in mind. For example, the simple feedback display for the patient in the bunker and on the control-room display, where they can easily see when they have reached the planned breath hold level, is a tool that provides reassurance to the patient that they are positively contributing to the success of the treatment. In turn, this gives us the confidence that we are performing a precise treatment. One of the major factors contributing to this is that the system automatically captures a reference surface for monitoring at breath hold level during external positioning imaging. Last but not least, the preparation for the treatment is very simple and straightforward – no additional camera is needed in the CT room, we simply acquire two planning CTs, one at breath hold and the other in free breathing.”
What are the benefits of tattooless workflows in your opinion and how exactly does ExacTrac Dynamic Surface help you achieve this?
Dr. Huertas: “There is great value in surface-guided patient prepositioning and set-up for patients, as they are no longer marked with permanent and invasive tattoos that constantly remind them of their cancer treatment. Patients have found that tattooless treatments not only provide a cosmetic benefit but may reduce their anxiety, making the whole procedure more comfortable for them. For us, the advantage is that we can perform prepositioning that is comparable in accuracy and speed, and we don’t have to deal with the tattooing process, which can be very time consuming and tedious.”
Mr. Rigaud: “When we started transitioning from laser-based to tattooless prepositioning, we established that the precision of prepositioning with ExacTrac Dynamic Surface is as accurate as with lasers, but more straightforward and seamless. With the ExacTrac Dynamic Surface technology we can track patient surface anatomy directly, via a structured blue light pattern projected onto the patient, which is acquired by two stereoscopic cameras. This enables us to very accurately track the surface without the need for any skin markings. We really appreciate the ease and speed of the setup process.”
What additional value do you see in relying solely on ExacTrac Dynamic and ExacTrac Dynamic Surface technologies in your department?
Dr. Huertas: “Our staff, especially the radiation therapists (RTT), truly appreciate the ease of use of the Brainlab software and how the ExacTrac Dynamic user interface allows them to make accurate but quick decisions as the treatment progresses. Because the software is the same on both systems, our RTTs were able to master the new ExacTrac Dynamic Surface system within days of installation. For example, they can use the ExacTrac Dynamic Surface system one day and then switch to the other linac with ExacTrac Dynamic the next day without any problems. We feel that this standardization really helps us to streamline our clinical routine. In addition, patients can be easily moved between the two systems as they share one common patient database giving us further flexibility in our patient scheduling.”
What is your vision for the future development of the department in terms of hypofractionated treatments and SBRT?
Dr. Huertas: “Nowadays, radiotherapy is going toward hypofractionation or extreme hypofractionation, to benefit more patients. This is backed up by more and more solid prospective data and will require an adaptation in our practice, from both medical and technical aspects. Delivering more dose per fraction comes with a higher risk for each fraction which can be mitigated by using advanced patient positioning and monitoring, which we feel confident in doing given the capabilities ExacTrac Dynamic offers combining SGRT and IGRT.
We have already started to use the system for lung and liver SBRT and plan to use it for prostate SBRT with the implanted marker workflow, taking advantage of advanced features like automated marker detection and active intrafraction motion management via stereoscopic X-Ray monitoring. When we perfect our program for such treatments, we can always upgrade the ExacTrac Dynamic Surface to the complete system, to expand our SBRT program and benefit even more patients.”
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