Clinical routine with Exac Trac Dynamic Surface

In the latest Brainlab Journal article, explore how the Radiotherapy Institute in Creil, Amethyst Radiothérapie France is revolutionising cancer treatment through SGRT, tattooless treatment and the breath hold workflow.

Now, with both ExacTrac Dynamic® and ExacTrac Dynamic Surface® for patient positioning and monitoring they are able to enhance daily clinical routines and ensure top-notch care for patients from all across the Sud l’Oise region of France.

Article below:

SGRT & Tattooless Treatment – How Radiotherapy Institute in Creil Is Improving Daily Clinical Routine with ExacTrac Dynamic Surface

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 l’Oise region in Creil, France which 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 cancers. 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.

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 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 the accuracy is that the system automatically captures a reference surface for monitoring at breath hold level during external positioning imaging. This is a real game changer, providing the highest accuracy on the market for this treatment, as we can be sure that we are treating the tumor as planned. 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 projected onto the patient, which is acquired by two stereoscopic cameras. In this way we can very accurately track the surface without the need for any skin markings. We really appreciate the ease and speed of this 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 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 system one day and then switch to ExacTrac Dynamic Surface 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 viewpoints. 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, given the features such as automated marker detection and active intrafraction motion management via stereoscopic X-Ray monitoring ExacTrac Dynamic offers. When we perfect our program for such treatments, we can always upgrade the ExacTrac Dynamic Surface to the complete system, which should be simple and quick, and therefore of great value for us.”