The technology and uses of on-treatment imaging in radiotherapy

24 MARCH 2015

THE TECHNOLOGY AND USES OF ON-TREATMENT IMAGING IN RADIOTHERAPY Venue: Stewart House, London CPD: 5 CREDITS

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON • Room 1

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Welcome and thank you for coming to ‘The technology and uses of on-treatment imaging in radiotherapy’ organised by The British Institute of Radiology.

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Programme

09:15 Registration and refreshments 09:40 Welcome and introduction

Dr Keith Langmack, Head of Radiotherapy Physics,

Nottingham Universities NHS Trust 09:45 Overview of cone beam CT (CBCT) and MV portal imaging technology

Dr Phil Evans, Professor of Medical Radiation Imaging, University of Surrey 10:15 Image guidance in radiotherapy: accuracy, frequency, dose, justification

Dr Ellen Donovan, NIHR Career Development Fellow,

The Royal Marsden NHS Foundation Trust 10:45 Refreshments 11:15 Clinical governance in on-treatment imaging

Mrs Ăšna Findlay, Senior Clinical Radiotherapy Officer, Public Health England 11:45 Image guided radiotherapy (IGRT) in clinical practice

Dr Angela Baker, Lead Research and Development Radiographer,

The Clatterbridge Cancer Centre 12:15 Optimisation of cone beam CT (CBCT): balancing dose and image quality

Dr Andrew Reilly, Head of Radiotherapy Physics,

Western Health and Social Care Trust 12:45 Lunch 13:45 Dose optimisation for soft tissue matching using a Likert scale

Dr Keith Langmack, Head of Radiotherapy Physics,

Nottingham Universities NHS Trust 14:15 Extraction of motion data from MOSAIQ

Mr Wayne Lomax, Product Manager, Imaging and Motion Management,

Elekta

14:30 Extraction of motion data from ARIA

Dr Andrew Reilly, Head of Radiotherapy Physics,

Western Health and Social Care Trust 14:45 Refreshments 2

15:15 Margin calculations in the context of daily online IGRT

Mr Sam Tudor, Head of Quality Control and Dosimetry,

University Hospitals Birmingham NHS Foundation Trust 15:45 IGRT and radiographer education

Mr Mark Collins, Senior Lecturer in Radiotherapy and Oncology,

Sheffield Hallam University 16:25 Questions 16:45 Close of event

Certificate of attendance This meeting has been awarded 5 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next 2 weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/on-treatmentimaginginRT

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Speaker profiles Dr Angela Baker Lead Research and Development Radiographer, The Clatterbridge Cancer Centre Angela Baker is Lead Research and Development Radiographer at The Clatterbridge Cancer Centre, Chair of the IGRT subgroup of RTTQA and Secretary for the UK SABR Consortium. Her departmental role includes responsibility for leading the development and implementation of new technologies. This includes IMRT/VMAT, IGRT, 4D-CT, SABR and gating techniques. Angela is currently running a number of developmental protocols at Clatterbridge using 4D-CBCT and 6 degrees of freedom (DoF) couch to improve treatment accuracy.

Mr Mark Collins Senior Lecturer in Radiotherapy and Oncology, Sheffield Hallam University Mark Collins is a Senior Lecturer at Sheffield Hallam University. He is actively involved in the teaching and development of the syllabus around imaging and treatment planning. His current research interests are related to decision making in 3D-CBCT as well as supervising a number of undergraduate and post-graduate research projects.

Outside of work he is Dad to two young children and a keen cyclist.

Dr Keith Langmack Head of Radiotherapy Physics, Nottingham Universities NHS Trust After graduation with a doctorate in molecular biophysics from Oxford, Keith joined the Radiotherapy Physics Team at Addenbrooke’s Hospital in Cambridge. He spent over 10 years there developing specific interests in brachytherapy and imaging. After a brief spell in Lincoln as Deputy Head of Radiotherapy Physics he moved to Nottingham in 2002, where he has been there ever since. His current interests are imaging and improving the efficiency of the radiotherapy process.

Dr Ellen Donovan NIHR Career Development Fellow, The Royal Marsden NHS Foundation Trust Ellen Donovan has worked as a Clinical Physicist in radiotherapy since 1992, firstly at Raigmore Hospital in Inverness, and since 1995, at the Royal Marsden Hospital, Sutton. From 2002 she was Principal Clinical Physicist with responsibility for radiotherapy treatment unit quality assurance and technique development. From 1999 to 2004 she undertook a part-time PhD that investigated intensity modulated 4

radiotherapy for the treatment of early stage breast cancer. In September 2010 she started an NIHR/CSO Post Doctoral Fellowship under the Healthcare Scientists award scheme. This was followed by an NIHR Career Development Fellowship award that started in January 2014.

Dr Phil Evans Professor of Medical Radiation Imaging, University of Surrey Phil Evans has a research interest in the application of physics and engineering to medical imaging, particularly with application to planning radiotherapy and maximising its accuracy of delivery. Phil joined The Centre for Vision Speech and Signal Processing (CVSSP) in June 2012 as Professor of Medical Radiation Imaging and with a keen interest in applying image vision and analysis methods to these important medical imaging problems.

Phil has a BSc in Physics from Aston University and a DPhil in Physics from The Queen’s College and the Nuclear Physics Laboratory in Oxford. Phil then joined The Joint Physics Department of The Institute of Cancer Research and Royal Marsden Hospital and then led a team there for some years working on imaging research in radiotherapy before joining CVSSP. Mrs Úna Findlay Senior Clinical Radiotherapy Officer, Public Health England As Radiotherapy Lead at Public Health England Úna’s role is to assist and support a range of organisations, including clinical departments, in addressing radiation protection issues that may affect radiological practice and patient safety.

This involves the analysis of radiotherapy error and near miss events (RTE) and promulgation of learning across the community; the provision of independent onsite support to individual departments; working with professional bodies to provide guidance on good practice; the provision of support to inspectorates and Department of Health, and liaison with UK professional bodies and international organisations. Úna is the current Chair of the Patient Safety in Radiotherapy Steering Group (PSRT), which is tasked with taking the key recommendations of Towards Safer Radiotherapy forward and an invited member of the Radiotherapy Board.

Mr Wayne Lomax Product Manager, Imaging and Motion Management, Elekta Wayne Lomax is the Product Manager for Imaging and Motion Management for ELEKTA’s software products and brings with him an extensive wealth of clinical 5

experience. Wayne has been at ELEKTA for over 5 years where he started as a Clinical Product Specialist giving direct clinical input to the R&D projects for imaging. He then progressed to become the Imaging Product Specialist and Product Manager within ELEKTA driving forward commercial product releases such as XVI, iView, MOSAIQ and joint development of a CT on Rails system with Toshiba Medical in Japan. Having trained as a Radiation Therapist in one of the UK’s and Europe’s leading centres and worked at numerous centres within the UK, Wayne has quickly established himself within his profession. His strong technical ability, forward thinking and passion for bringing value to ELEKTA’s users, keeps ELEKTA at the leading edge of image guided radiotherapy, both in development and practice.

Dr Andrew Reilly Head of Radiotherapy Physics, Western Health and Social Care Trust Andrew Reilly is Head of Radiotherapy Physics at Altnagelvin Hospital, Londonderry.

Throughout his career he has supported the clinical use and development of radiotherapy imaging technologies and worked towards improved systems integration. He has a particular interest in bridging the gap between different imaging disciplines and optimising imaging across the radiotherapy process. He is founder of the IQWorks project, leads the Radiotherapy Imaging User Group and provided physics support under the national NRIG mentoring programme for IGRT implementation.

Andrew served as Chairman of the BIR Radiation Physics and Dosimetry Committee until 2009, was a member of BIR Council from 2010 to 2013, represents the BIR on the DH Medical Physics Expert working group and currently chairs the BIR Informatics and Clinical Intelligence Special Interest Group (SIG).

Mr Sam Tudor Head of Quality Control and Dosimetry, University Hospitals Birmingham NHS Foundation Trust Sam Tudor is Head of QC and Dosimetry at University Hospitals Birmingham. He has interests in the use of radiobiological modelling to inform the effect of geometric uncertainties and imaging strategies, as well as the dosimetry of complex, small or unflattened beams. He is currently studying for a part-time PhD in the effect of geometric uncertainties on treatment success.

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Abstracts Overview of cone beam CT (CBCT) and MV portal imaging technology Dr Phil Evans Modern radiotherapy uses image guidance to target the treatment accurately to the target avoiding normal tissue as efficiently as possible. This presentation will comment on some of the commonly used techniques for imaging in image guided radiotherapy (IGRT).

Several techniques exist and there is currently no clear evidence that a single one is best to use in all circumstances. The methods to be discussed include kilovoltage cone beam CT (Elekta and Varian), megavoltage CT (both cone beam and slice from Siemens and Tomotherapy), planar imaging (both kV radiography and MV portal imaging) and newer implementations of these approaches including the cyberknife and brain lab marker based tracking systems and the vero gimballed head system.

Competing technologies include ultrasound for soft tissue visualisation, the calypso, implanted electromagnetic transponder approach and the MR treatment unit.

The characteristics of these key systems will be presented and compared with a discussion of the pros and cons of the various approaches. In addition the combination of methods will be discussed. This will include, as the primary example, the combination of kV X-ray with optical systems for tracking motion. The doses delivered by the X-ray based systems will be discussed, both in terms of theoretical considerations and dose demonstrated by available systems.

Learning outcomes: • Understanding of the current state of the art for radiotherapy imaging technology • Understanding of the pros and cons of the available radiotherapy imaging systems • Understanding of dose considerations in radiotherapy imaging • Understanding of some of the outstanding challenges in radiotherapy imaging • Understanding of the non-ionising radiation approaches to radiotherapy imaging Image guidance in radiotherapy: accuracy, frequency, dose, justification Dr Ellen Donovan Background: Image guidance is a crucial part of the radiotherapy chain and is integrated within high quality radiotherapy treatment. It is the role of image guidance in ensuring highly accurate and precise radiotherapy treatment that provides its justification.

This presentation is based on the definition given in the National Radiotherapy Implementation Group Report 2012 [1] that states “Image guided Radiotherapy (IGRT) is any imaging at pre-treatment or delivery …that improves or verifies the accuracy of radiotherapy”.

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Image guided radiotherapy protocols: Appropriate modifications should be made to the standard imaging protocols set up on IGRT equipment when it is installed. These should focus on providing the image quality necessary to achieve an accurate radiotherapy delivery. Appropriate use of verification protocols is good practice, and can reduce the imaging dose component of total organ dose, if this is of concern.

Impact of image guidance: Two studies (Hawkins et al [2] Donovan et al [3]) are used to demonstrate a quantification of the benefit of IGRT. Education and learning outcomes: • Appreciation of the important of image guidance in radiotherapy and its justification as an integral component of a radiotherapy episode • Understanding of the relative contribution of radiotherapy and imaging dose to total organ dose • Use of standard verification protocols to balance the accuracy, frequency and dose of on-treatment imaging Key references: 1. National Radiotherapy Implementation Group. Image Guided Radiotherapy (IGRT) Guidance for implementation and use; 2012 2. Hawkins, MA, Brooks, C, Hansen, VN, Aitken, A, Tait, DM. Cone beam computed tomography-derived adaptive radiotherapy for radical treatment of esophageal cancer. Int J Radiat Oncol Biol Phys 2010; 77:378–383.

3. Donovan EM, Brooks C, Mitchell RA, Mukesh M, Coles CE, Evans PM et al. The Effect of Image Guidance on Dose Distributions in Breast Boost Radiotherapy. Clin. Oncol 2014; 26 (11); 671–676 Clinical governance in on-treatment imaging Mrs Úna Findlay The clinical use of image guided radiotherapy has increased rapidly in the last few years. Portal imaging is being superseded by cone beam CT (CBCT) in a number of sites. However there are on-going debates around imaging frequency, dose measurement and margin calculations. The importance of safely managing the associated dose burden for the patient should also be carefully considered.

Clinical governance has been defined as a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. The Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) is legislation intended to protect the patient from the hazards associated with ionising radiation in the UK. 8

This presentation will review the role of clinical governance and the implications of the IR(ME)R in concomitant imaging processes in radiotherapy with a focus on the justification and optimisation of these exposures.

Key reference: Scally G and Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal 1998; 317 (7150), 61-65.

Image guided radiotherapy (IGRT) in clinical practice Dr Angela Baker Following the publication of national guidelines, image guided radiotherapy has been widely implemented across the UK and IGRT is being used throughout the treatment process. The current status of IGRT in the UK will be discussed and clinical cases presented where the technology is being utilised with consideration of site specific, individualised protocols. The role of clinical trials in the evaluation and implementation of image guided radiotherapy will be described together with training implications of the technology. The advent of image guidance techniques provides opportunities and challenges within the department but also many opportunities for role changes. The presentation will finish discussing the role of adaptive radiotherapy and future technologies.

Educational aims: • To consider advanced IGRT and adaptive processes and their impact on departmental roles Learning outcomes: • To demonstrate the ability to critically evaluate site specific image guided techniques • To demonstrate knowledge of the types of adaptive techniques currently available • To consider the impact of changing roles within the multi-professional team Optimisation of cone beam CT (CBCT): balancing dose and image quality Dr Andrew Reilly CBCT at the point of treatment delivery is now widely accessible and its adoption has increased dramatically since the publication of the NRIG report on implementing IGRT and its supporting mentoring programme. Although CBCT undoubtedly makes more information available about patient setup than ever before, it is also the treatment imaging modality with the highest patient dose 9

burden. Care must therefore be exercised when using CBCT for daily imaging.

Optimisation involves balancing competing factors: ensuring images acquired are suitable for the clinical task whilst minimising the burden to the patient.

Methods for objectively evaluating clinical image quality are explored, including linking “physics” measurements on phantoms back to the clinical task. The importance of the human observer is emphasised.

There is significant debate within the radiotherapy community regarding the measurement, quantification and management of concomitant dose from imaging. A pragmatic approach to this is suggested by building on experience from clinical trials and harnessing data automatically collected through routine workflow activities. The potential role of imaging dose reference levels is considered and the development of peer support networks is suggested, encouraging cancer centres with similar equipment and case-loads to share protocols and experiences.

Balancing the relative importance of the various tasks across the radiotherapy process is an important element of optimisation in radiotherapy imaging.

Opportunities for developing robust CBCT optimisation strategies through close multi-disciplinary working and building relationships with peers in diagnostic imaging are considered.

A variety of real-world clinical examples is used to illustrate the challenges and opportunities discussed throughout the presentation.

Dose optimisation for soft tissue matching using a Likert scale Dr Keith Langmack The presentation will start with a discussion of clinical image quality. Image quality is a complex measure as it has a number of different aspects to it. It is possible to identify four dimensions of image quality: physical (e.g. DQE); psycho-physical (response to visual stimuli); observer performance; and diagnostic performance.

In verification imaging we are not carrying out a diagnosis, however, we could replace this with “matching performance”. For this study we defined image quality in relation to the specific matching task (soft tissue matching) such that the image carried enough information to allow a decision (matching) to be made with an acceptable degree of certainty.

The remainder of the presentation will describe the study. The Nottingham VAMT prostate protocol requires daily CBCT imaging prior to treatment. At the introduction of this type of imaging we used the manufacturer supplied pre-sets.

These were found to give adequate image quality for soft tissue matching. Once we had become confident with this procedure, we investigated if the imaging dose could be reduced whist maintaining adequate image quality. Phantom

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studies with the cat phan and CRIS visible human pelvis phantom indicated that it might be possible to reduce the imaging dose by as much as 33%. However, patients are far more variable than phantoms, so we decided to carry out a service improvement study with a cohort of around 20 patients.

For this study we set-up three dose level pre-sets within our XVI / Mosaiq system—full dose, 80% dose and 63% dose. To measure image quality we set up a four point Likert scale (excellent, no artefacts; good, few artefacts; poor, just able to match; unsatisfactory, not able to match). This was discussed with the radiographers on-set who would be doing the matching so that they understood what was required. The study protocol required the treatment radiographers to assess and record image quality on a daily basis. For the first 12 fractions the “100% dose” pre-set was used. For the next 12 fractions the “80% dose” protocol was used with the proviso that if the image quality proved unsatisfactory then they were able to revert to the previous dose level. For the final fractions the “63% dose” protocol was used, again with above proviso.

The data was analysed with the Freidman test followed by the Wilcoxon signed rank test with Bonferroni adjustment for repletion. This analysis will be explained in the presentation. The results of the study showed that we could use the “80% dose” protocol for all patients, with the “63% dose” protocol for patients with a lateral separation less than 35 cm. This has now been clinically implemented with no reported issues. We aim to repeat this study for other body sites where we routinely use CBCT imaging.

Extraction of motion data from MOSAIQ Mr Wayne Lomax ELEKTA’s MOSAIQ Oncology Information System has a wealth of data and knowledge relating to not only the patient and its care path but also your radiotherapy and oncology departments. One such data MOSAIQ is able to record from numerous vendors via spatial registration objects, registering images within MOSAIQ or general manual recording is offset data from daily IGRT. During this session we intend to cover how to extract daily IGRT offset data for a patient by general reporting included in MOSAIQ for use outside of the MOSAIQ environment. We will also cover where and how you can get help or learn how to create custom more complex reports from your MOSAIQ data. During the session we will also touch on some other areas within the ELEKTA IGRT products where data can be extracted relating to 4D motion data. The session will also give a glimpse into the future vision of ELEKTA software and information guided cancer care.

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Extraction of motion data from ARIA Dr Andrew Reilly ARIA as an oncology management system (OMS) is underpinned by a database that tracks every aspect of the treatment delivery process. This includes setup verification imaging, details of the image matching process, respiratory motion waveforms and couch positions during imaging and treatment. Additional information such as the timings of different events and the operator taking responsibility for the treatment are also recorded.

This presentation describes the extraction of data from ARIA to characterise inter- and intra-fraction motion. The data can be utilised to calculate random and systematic setup errors, which in turn may feed into margin calculations using the algorithms in the RCR “On Target� report or other patient setup models published in the literature. Evaluating respiratory waveform information over time enables changes in breathing motion to be identified and facilitates investigation of potential synchronisation issues between the movement of internal anatomy and that of the external surrogate.

A number of data extraction methods are considered, all suited to different operational conditions yet all yielding the same output data. These include using tools built-in to the ARIA user interface, advanced ARIA reporting, ARIA scripting and ARIA analytics.

Although the NRIG report on implementing IGRT encourages the routine monitoring and analysis of setup errors this has not yet been fully realised nationwide. A potential community initiative is suggested as a means of achieving this.

Margin calculations in the context of daily online IGRT Mr Sam Tudor In the absence of IGRT, and to some extent where IGRT techniques are performed less frequenty and off-line, there exist significant sources of translational geometric inaccuracy, including setup error and daily internal motion of the target within the patient. These sources of error are, however, typically easy to measure and incorporate into a CTV-PTV margin formulae such as the van Herk formula (BIR 2003 [1], van Herk et al. [2]). The incorporation of other components, including rotational error, intrafractional motion and delineation error, into the van Herk methodology poses some problems, but when these components were determined to be relatively small, the exact method of their consideration had little impact on the calculation of the total CTV-PTV margin.

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However, in the context of daily, online IGRT, the larger and more easily considered components of uncertainty are the first to disappear. Less scrutable components such as rotational error and intrafractional motion are less likely to be corrected by the IGRT system, and they are joined by an additional component of registration error that can be similarly difficult to consider how to measure and act on.

This presentation discusses some of the features of residual components of uncertainty that typically remain after the introduction of daily online IGRT, and presents techniques to incorporate some of these into conventional margin formulae.

A brief discussion of margin formulae based on radiobiological modelling will follow together with consideration of their worth in light of the limited published clinical evidence of margin reduction with IGRT. Key references: 1. BIR. Prepared by a Working Party of the British Institute of Radiology.

Geometric uncertainties in radiotherapy: defining the planning target volume.

London, UK: 2003. (ISBN 0-905749-53-7).

2. Van Herk M, Remeijer P, Rasch C and Lebesque J.V. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int. J. Radiat. Biol. Phys. 2000; 47 (4), 1121-1135.

IGRT and radiographer education Mr Mark Collins The routine implementation of 3D imaging during treatment verification has been one of the largest changes in radiotherapy practice in the last 10 years. The speed at which this technology has been implemented has raised a number of issues for the radiotherapy community and the professionals involved in the education of the workforce.

Higher Education Institutions (HEIs) play a large role in the training of therapy radiographers. The ultimate goal of the HEI is to train graduates that are fit for purpose in the modern radiotherapy department. It is essential that HEI’s develop their curriculum and adapt methods of delivery to keep pace with the implementation of this technology.

There are a number of questions and challenges that must be overcome before this can happen. Therapy radiographers typically spend around 50% of their training in a clinical department and 50% in academia. At Sheffield Hallam University (SHU), students are based at one site for all clinical practice with the exception of a 3 week elective placement. This allows students to become familiar 13

with the protocols and practices at this site, as well as giving them the skills and experience they need to work in the wider radiotherapy community. As a result of this method, students are exposed to working practices including radiotherapy treatment techniques and IGRT practice in one placement environment.

A number of studies have demonstrated that IGRT practice varies significantly across the UK. These studies reflect the experiences of students at SHU, with students reporting very mixed experiences of IGRT training whilst on placement.

As with other aspects of the undergraduate syllabus, IGRT training should ideally be delivered in partnership with the HEI and clinical departments both taking an active role. At times, the implementation of this can be problematic due to a number of constraints. These include the availability of the technology in some clinical sites as well as staffing resources and varying inter-departmental staffing structures for image review.

The question of what level of IGRT skills and competences are required of new graduates remains unanswered, and as a profession we need to work towards defining common competencies. Over the last 2 years, SHU has significantly developed its IGRT teaching syllabus. In the second and third years of their training, students carry out a number of practical sessions using case studies on Varian Aria. These have been well received by students, but a common theme of the feedback is that students would like more time for these sessions.

SHU is working closely with its local clinical departments to train its graduates to have the skills and competencies they need. They will be conducting a national survey in late spring to gain a wider perspective on undergraduate IGRT training.

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