© 2015 Vision RT Ltd

MORE THAN JUST MOTION MANAGEMENT Tim Nicholson - Vision RT Ltd 4th August 2013

Cedars-Sinai Medical Center

Presenter

Title, Vision RT Ltd MM-DD-YY | Venue

Presenter

Title, Vision RT Ltd MM-DD-YY | Venue

3D PATIENT TRACKING FOR RADIATION THERAPY

© 2015 Vision RT Ltd

VISION RT: COMPANY VISION

Setting a new standard of care in motion

management during radiation therapy

Non-invasive, non-ionizing, non-contact, real-time

Reduce treatment time

Improve patient comfort

Increase patient safety

Complex treatments -> routine

Standard of care -> Every Linac, every patient, every fraction

© 2015 Vision RT Ltd

USER MEETING 2015

Highlights from Meeting:

May 14-15 2015

Denver, CO

EVERY PATIENT, EVERY FRACTION, EVERY TREATMENT

© 2015 Vision RT Ltd

PRODUCT OFFERRING

AlignRT®

Patient setup and surveillance

GateCT®, GateRT®

4D CT and respiratory gating

AlignRT® Plus:

Frameless SRS Module

All FDA Cleared Products

© 2015 Vision RT Ltd

USER COMMUNITY INCLUDING

Almost 400 systems installed worldwide (backlog: >125) installed in more than 30 NCI

designated cancer centers in the US:

Cleveland Clinic

Dana Farber Cancer Institute

Dartmouth-Hitchcock Medical Center, NH

Emory University

Huntsman Cancer Hospital

Massachusetts General Hospital

Mayo Clinic, Rochester

Memorial Sloan Kettering Cancer Center

MD Anderson Cancer Center: Houston, Orlando

Ohio State University

Procure: Indiana (Training Center); Oklahoma City

21st Century Oncology, US Oncology

University of California: San Diego, Davis, San Francisco

University of Florida: Gainesville, Jacksonville

University of Maryland

University of North Carolina

University of Iowa

University of Pennsylvania

UT Southwestern

© 2015 Vision RT Ltd

SYSTEM OVERVIEW

Key functions of Vision RT technology

Patient setup

Intra-fraction surveillance

4D treatment planning and delivery

© 2015 Vision RT Ltd

REAL TIME 3D SURFACE IMAGING: CORE PRINCIPLES

Camera Calibration 3D Triangulation

AlignRT camera unit

© 2015 Vision RT Ltd CONFIDENTIAL

REAL TIME 3D SURFACE IMAGING: CORE PRINCIPLES

Stereo matching algorithm

Match all possible corresponding points

Produce 3D triangulated mesh

Other approaches:

- Structured light

- Laser stripe

© 2015 Vision RT Ltd

Christoph Bert, Katherine G. Metheany, Karen Doppke, George

T. Y. Chen. A phantom evaluation of a stereo-vision surface

imaging system for radiotherapy patient setup. Med. Phys.

32(9), pp. 2753-2762, Sep 2005.

P.J. Schöffel, W. Harms, G. Sroka-Perez, W. Schlegel and C.P.

Karger. Accuracy of a commercial optical 3D surface imaging

system for realignment of patients for radiotherapy of the

thorax. Physics in Medicine and Biology; 52: 3949-3963; June

2007.

Results comparing AlignRT outputs with those measured from strain gauges

STUDIES: SYSTEM ACCURACY

© 2015 Vision RT Ltd

BREAST APPLICATIONS

This customer quote reports on the clinical use and performance of Vision RT products by independent users. This has not been validated by Vision RT and thus is not

endorsed by Vision RT. Users of Vision RT’s products should develop and validate their own workflows consistent with clinical practice within their facility.

We’ve had 53 out of 54 patients where we have not had to repeat their weekly X-Ray

images, so 98.1% of our patient’s weekly X-Ray images have been approved without

need to repeat. That is a significant finding for us – it’s showing us that we’re getting a

dose reduction because we’re not having to repeat X-Ray images on these patients, and

it’s also showing us how reliable the AlignRT system really is in patient positioning.

Heather Warmouth BS RT(T), Radiation Therapist, Fletcher Allen Health Care

General breast

Prone breast

DIBH (left breast): New data

from SPECT study; User

Meeting, ASTRO

© 2015 Vision RT Ltd

D.P. Gierga, M. Riboldi, J.C. Turcotte, G.C. Sharp, S.B. Jiang, A.G. Taghian, G.T.Y. Chen. Comparison of Target

Registration Errors for Multiple Image-Guided Techniques in Accelerated Partial Breast Irradiation. International

Journal of Radiation Oncology Biology Physics. 70(4); p. 1239-1246; March 2008.

A.J. Chang, H. Zhao, K. Moore et al. Video surface image guidance for external beam partial breast irradiation.

Practical Radiation Oncology; August 2011

D. Gierga, J. Turcotte, G. Sharp et al. A Voluntary Breath-Hold Treatment Technique for the Left Breast With

Unfavorable Cardiac Anatomy Using Surface Imaging. International Journal of Radiation Oncology Biology Physics.

July 2012.

X. Tang PhD, T Zagar, E. Bair et al. Clinical experience with 3-dimensional surface matching-based deep inspiration

breath hold for left-sided breast cancer radiation therapy. Practical Radiation Oncology; p. 151-158; May-June 2014

New SPECT study (UNC): Initial results presented at User Meeting; Additional data to be presented at ASTRO

BREAST APPLICATIONS: PUBLISHED STUDIES

© 2015 Vision RT Ltd

CLINICAL APPLICATIONS: BREAST

Vision RT is a very good way to

support the breath hold technique to

reduce heart exposure to our

patients with left sided breast

cancer Larry Marks MD

Chairman Radiation Oncology,

UNC, Chapel Hill

I think this is a very crucial part of

my breast cancer care for patients

with left sided breast cancer

Ellen Jones MD PhD

Vice Chair Radiation Oncology,

UNC, Chapel Hill

DIBH Patient Treatment

© 2015 Vision RT Ltd

DEFINE REFERENCE TREAT

CLINICAL APPLICATIONS: BREAST

Acquire DIBH

CT data

SETUP PATIENT

Set up to

breast during

DIBH using

RTDS

Define ROI

around

breast

Track DIBH and

enable when in

tolerance

DEEP INSPIRATION BREATH-HOLD (DIBH)

© 2015 Vision RT Ltd

Background Traditionally, SRS has been niche, invasive, expensive and time-consuming

GammaKnife: Lars Leksell (1949) → Elekta

Cyberknife (Accuray)

Novalis (BrainLAB)

Linac + biteblock

FRAMELESS SRS

© 2015 Vision RT Ltd CONFIDENTIAL

Why Frameless SRS?

Patient comfort: Open mask

Safety: Continuous monitoring of any motion under

the mask in real time

Accuracy: Sub millimetric; Correct for couch walk

Efficiency: Frameless SRS on conventional Linac

→ 20 minute treatment time

FRAMELESS SRS

© 2015 Vision RT Ltd

SRS Calibration

Imaging of internal spheres (MV) and external surface (AlignRT): Software calculates for isocenter

mismatches

Allows high accuracy tracking of patient for all couch angles

Verify kV and lasers

VRT, MV, kV isocenter(s) coincident

FRAMELESS SRS

© 2015 Vision RT Ltd

3Degree Head Adjuster

FRAMELESS SRS

Accurate and efficient

Allows the precise corrections of pitch, yaw and roll rotations to the head

Adjustments can be applied to within a tenth of a degree

Saves time (~10 mins per treatment - UCSD) -> increases patient throughput

Bolts on with quick release clamps to standard couch tops

© 2015 Vision RT Ltd

SETUP PATIENT DEFINE

REFERENCE TREAT

CLINICAL WORKFLOW

Acquire CT

scan and

define ROI

Track patient: Beam hold

if motion detected

FRAMELESS SRS

Acquire

CBCT data

& reference

surface

Plan for

couch

rotations

UCSD workflow

Preliminary

setup: RTDs

© 2015 Vision RT Ltd

FRAMELESS SRS: CLINICAL STUDIES

Nhat-Long L. Pham, Pranav V. Reddy, James D. Murphy, Parag Sanghvi, Jona A.

Hattangadi-Gluth, Grace Gwe-Ya Kim, Laura Cervino, Todd Pawlicki, Kevin T. Murpy,

Frameless, real-time, surface imaging-guided radiosurgery: update on clinical

outcomes for brain metastases, Translational Cancer Research, 3, 4, 351-357,

August, 2014

163 patients: outcomes study, 6.7 months follow up; equivalent to frame based.

Anthony J. Paravati, Ryan Manger, Jasmine D. Nguyen, Sofia Olivares, Gwe-Ya Kim,

Kevin T. Murphy, Initial clinical experience with surface image guided (SIG)

radiosurgery for trigeminal neuralgia, Translational Cancer Research, 3, 4, 333-337,

August, 2014

First 7 TN patients at UCSD

H. Pan, L. Cerviño, T. Pawlicki et al., Frameless, Real-Time, Surface Imaging-Guided

Radiosurgery: Clinical Outcomes for Brain Metastases, Neurosurgery, 71(4), 844-

852, October, 2012

44 patients: outcomes study, 6 months follow up; equivalent to frame based

© 2015 Vision RT Ltd

No invasive frame is required

CLINICAL APPLICATIONS: SBRT

Patient exposed; made as comfortable as possible

CDR CIVCO

© 2015 Vision RT Ltd

SETUP PATIENT

CLINICAL WORKFLOW

CLINICAL APPLICATIONS: SBRT

Preliminary

setup: RTDs

Acquire

AlignRT

reference

DEFINE

REFERENCE

Acquire CT

scan and

define ROI

TREAT

Track patient: Beam hold if motion

detected

Acquire CBCT

data: Apply shifts

to patient

© 2015 Vision RT Ltd

SARCOMA EXTREMITIES

Play video

D. Gierga, J. Turcotte, L. Tong et al. Analysis of setup uncertainties for extremity sarcoma

patients using surface imaging. Practical Radiation Oncology. 2013.

“Intrafraction motion is small. Interfraction motion can exceed typical PTV margins

and daily imaging should be utilized to reduce setup variations. Surface imaging may

reduce setup errors and is a feasible technique for daily image guidance.”

© 2015 Vision RT Ltd

CLINICAL APPLICATIONS: RESPIRATORY GATING

© 2015 Vision RT Ltd

4D CT

Position

patient and

acquire scout

CT scan

: RESPIRATORY GATING

Track

patient’s

breathing until

it is regular

Measure phase

of full breathing

cycle for 4D CT

Select tracking

points and

start 4D scan

Review data;

export to 4D

workstation;

reconstruct

4DCT

4D PLANNING

4D treatment

planning: determine

need for gating

GATED TREATMENT

Phase based

respiratory gating

Displacement

based gating

Play video

© 2015 Vision RT Ltd

EVERY PATIENT, EVERY FRACTION, EVERY TREATMENT

Within a few months of using AlignRT, we

realized that we could no longer justify treating

our patients without it. Consequently, we have

deployed additional systems for our satellite

facilities to be used for all treatments, including

DIBH, SBRT and SRS

Nancy Wiggers MD, Northside Hospital, GA

© 2015 Vision RT Ltd

DEFINING THE STANDARD OF CARE IN MOTION MANAGEMENT