1. Precise Patient Positioning
Immobilization for IMRT

2. Why IMRT? Increased Dose To Target Volume Spare Adjacent Tissue
Tighter Margins With Fewer Complications
Clinically Proven Better Local Control
Why has IMRT become such an important topic?
2 reasons: 1) the ability to produce higher doses in the target volume, and
2) better able to spare adjacent normal tissue, which means fewer complications,
both of which give clinically proven better local control

3. A Quality IMRT Program STARTS with Quality Set-Ups and Precise Immobilization
IMRT depends on accurate, reproducible, and documentable patient positioning. The quality of the therapy delivered depends on the quality of the set-up and the means used to immobilize the patient. Without careful attention paid to this step, proper IMRT is not possible.

4. Patient positioning is the first step in the IMRT process
Success depends on creating effective, comfortable, and reproducible setups
This slide shows the successive stages of the IMRT process. Patient positioning is the first step in this sequence. The outcome of every successive step in the IMRT process is dependent on your ability to create effective, comfortable, and reproducible setups.

5. Immobilization Needs to be Revisited for IMRT
The patient is on the table longer during simulation and treatment. The beam is on longer.
More fields, segmented fields, and multiple junctions within segmented fields.
Escalated Doses and Critical Structures
Tighter Margins = Greater Precision
Documentation of Immobilization is Required for IMRT
These are some key reasons why patient immobilization is critical to successful IMRT: (read slide)
All point to the need for greater precision and immobilization.
Remember: patient movement increases as table time increases.
Documentation is required in order to bill appropriately.

6. “Perfect” IMRT Immobilization Means
Absolute Precision
Absolute Immobilization
Absolute Radiolucency
Absolute Reproducibility
Absolute Verification
Absolute Documentation
BUT WE DON’T LIVE IN A PERFECT WORLD!
Precision: With IMRT we want to define the treatment volume precisely so that we can deliver escalated doses and at the same time spare critical structures such as the brain and spinal cord.
Immobilization: Once the patient is positioned, we need to ensure that patient movement does not interfere with the accurate delivery of the dose, possibly exposing critical structures to the therapy beam.
Radiolucency: Ideal IMRT immobilization devices should not attenuate the therapy beam, which could complicate treatment planning and dose delivery.
Reproducibility: Patients receive IMRT over a series of therapy sessions, and we need each setup to be identical so that the appropriate radiation dose is given.
Verification: For IMRT we need to know that the patient setup is correct, that the treatment volume is correctly identified, and that the dose delivered is correct. Verification relies on…
Documentation: Documenting and recording the use of indexing marks and labeled device settings, and using and recording patient fiducials and markers enables the accurate delivery of IMRT, and allows for appropriate billing.
In the “ideal” world we want IMRT Immobilization devices to have these qualities. Since we live in the “real” world, we look for immobilization devices that come as close as possible to these ideals.

7. Characteristics of IMRT Immobilization Devices
IMRT Immobilization Devices Must Meet Certain Criteria
Provide Highly Effective Immobilization
Provide Comfortable Patient Setups
Be Compatible With Newer Imaging Techniques (CT/MRI/PET)
Be Reproducible and Documentable
Work With Indexing Treatment Tabletops
Produce Minimal Attenuation of Therapy Beam (Carbon Fiber Composites)

8. Highly Effective Immobilization
For IMRT Patient Movement Must Be Restricted
Escalated Doses
Need to Spare Critical Structures (e.g. spine)
Complex fields
Tighter Margins
All require greater precision in dose delivery
Longer Treatments
Patient movement increases as table time increases
Customized Restraints and Supports are More Effective
Examples Include: Thermoplastic Masks
Customized Vacuum Cushions
Two-Part Foam
Bite Blocks

9. Enhanced Patient Comfort
Extended Treatment Times Mean Longer Immobilization
Patient movement increases as table time increases
Immobilization Devices That Are Customized to Each Patient Provide Better Support and Comfort
Examples Include: Thermoplastic Masks
Customized Vacuum Cushions
Two-Part Foam
Bite Blocks
MoldCare® Pillow
Using methods that are individualized to each patient promotes patient comfort and results in more effective immobilization. Some examples shown here are two-part foaming agents, vacuum bags, and conformable head and neck supports (Mold Care).

10. Compatibility With Current Imaging Techniques
CT MRI PET
Devices need to be compatible with current imaging technology. Newer modalities for patient imaging and treatment planning requires immobilization devices that will not interfere with the quality of that imaging.
Some obvious and not so obvious factors to consider are:
Metal parts– cause artifact on CT scans, and if ferromagnetic can cause artifact or image degradation on MRI
Conductive coatings or materials– can also cause artifact or image degradation on MRI
Thick plastic parts can cause undesirable beam attenuation and complicate treatment planning
Large immobilization devices may not fit into the small bores of CT or MR scanners

11. Reproducible and Documentable
Setups Must Be Identical For Each Treatment Session
Index To Tabletops
Labeled Device Settings
Provide Verification Of
The Treatment Setup
Documentable
Devices used for IMRT must be reproducible and documentable. Features such as marked device settings and the ability to lock the device down to indexed treatment tabletops allows each setup to be documented and reproduced for each treatment session. Patient fiducials (skin tattoos, implanted seeds) allow verification of the treatment setup. Shown here are Beekley spots.
Beekley Spot® Photo courtesy of Beekley

12. Indexing Tabletops For IMRT
More Than One Version Available
Must Be On Simulators As Well As Therapy Machines
Devices Index Using Lock Down Bars
Indexing Points Are Labeled And Documentable
Allow Efficient, Quick, and Reproducible Setups
Many treatment tables now have indexing tabletops. In order to index devices, indexing treatment tabletops are required for simulators (CT, MR, PET) as well therapy machines. There are currently more than one design of indexing tabletops available. Patient immobilization devices lock down to the tabletop by use of lock-down bars. These first attach to the immobilization device, then securely attach to the indexing points on the treatment tabletop. The indexing points are labeled and documentable. This approach promotes efficient, reproducible setups from simulation through treatment.

13. Carbon Fiber Immobilization Devices
Why Carbon Fiber?
Rigid and Rotationally Stable
Low Attenuation
Lightweight For Ease Of Use
Accept Thermoplastic, Vacuum Bags, etc. For Customized Setups
Adjustable, Reproducible, Documentable

14. Customizing Your Setups
Many Factors Affect Immobilization And Therapy
Location of tumor and adjacent critical structures
Patient Specific Individual Needs
Age
Size and Weight
Health and Flexibility
Special Needs (prosthetics, etc.)
Immobilization Decisions Based On
Overall Effectiveness  what works best in your facility
Available Resources  maximize limited funds and space
Personal Preference  experience counts!
Reimbursement  insurance variability can dictate choices
Customizing setups is critical to effective IMRT, as many factors can affect immobilization and therapy:
Patient size and weight.
Patient age.
Patient overall health and flexibility.
Special needs– (implants, prosthetics,physical anomalies, etc.)
Determining what immobilization to use involves several considerations:
Overall effectiveness– what works best in your facility.
Available resources– limited funds and limited space. Need to maximize the economy of both.
Personal preference– again, what works best for you.
Reimbursement– variability in insurance reimbursement may dictate your choices.

15. Billing for IMRT Billing Includes Based On Treatment Complexity
Treatment planning
Mapping compensator blocks or using MLC
Patient setup for each therapy session
Based On Treatment Complexity
Simple
Intermediate
Complex
Documentation Required To Justify Device Used

16. Billing for IMRT (cont.)
A typical course of radiation therapy will have 2-12 charges for devices depending on the complexity of treatment and treatment site
Immobilization devices should be billed at simulation
Treatment field devices should be billed at the beginning of treatment and later in the course of treatment if additional devices are required
Only one device can be billed per port. Choose the device with the highest complexity.

17. Billing Coding
Billing codes are updated quarterly and published annually in Current Procedural Terminology (CPT). These codes are defined by the ACR/ASTRO Joint Economics Committee.
There is no national set of billing policies for Medicare.
Each local Medicare carrier has some limited freedom to establish their own policies.
IT IS VERY IMPORTANT TO CHECK WITH YOUR CARRIERS TO SEE IF SIGNIFICANT CODES HAVE BEEN UPDATED.
Remember: Billing CPT codes may changed or be replaced. Check with your local carriers to see if they have updated or removed significant billing codes.

18. Simple Treatment Complexity Immobilization Devices
These are generally prefabricated, multi-Use devices.
Blue Prone Pillow
Rings
Shoulder Retractors
Silverman/Timo Head Supports
Butterfly Boards
Some examples of simple immobilization devices. All are reusable, but not adjustable between patients.

19. Intermediate Treatment Complexity Immobilization Devices
These facilitate use of other devices and/or have some level of adjustability.
Belly Board
Bite Blocks
Breast Boards
Pituitary Headholder
Thigh Bolster

20. Complex Treatment Complexity Immobilization Devices
Documentation is required to bill for complex immobilization devices.
Devices can be customized
for each patient.
Two-Part Foam
Custom Head Supports
Thermoplastic
Vacuum Cushions

21. Verification Techniques For IMRT
Treatment target volume must be verified before each therapy session
Verification may rely on:
External Landmarks
Device Associated Markings
Internal Fiducials

22. Verification Techniques For IMRT
External Landmarks
Ink tattoos
Still the most popular and commonly used method.
Uses a small tattoo as a fiducial marker for laser alignment.
Relies on permanence and relation of skin markings to internal structures.
Drawback is body mass loss during the course of a treatment regimen.
Skin Markers (EZ Port®, Beekley Spots®)
Ink tattoos–
Still the most popular and commonly used method.
Uses a small tattoo as a fiducial marker for laser alignment.
Relies on permanence and relation of skin markings to internal structures.
Drawback is body mass loss during the course of a treatment regimen.
Implanted fiducial markers–
Permanently implanted seed visible through imaging.
Provides positive verification of target treatment volume.
Invasive; requires surgical or transcutaneous placement.
Greater cost.
Indexing—
Immobilization device indexed to treatment tabletop.
Simple, documentable, and reproducible.
Can not definitively localize internal organs/ target treatment volumes.

23. Verification Techniques For IMRT
Device Associated Markings
Indexing Tabletops
Immobilization device indexed to treatment tabletop.
Simple, documentable, and reproducible.
Can not definitively localize internal organs/ target treatment volumes.
Labeled Device Markings
Note settings of board angles, arm supports , etc.

24. Verification Techniques For IMRT
Internal Fiducials
Implanted Fiducial Markers (Gold Seeds)
Permanently implanted seed visible through imaging
Provides positive verification of target treatment volume
Invasive; requires surgical or transcutaneous placement
Greater cost
Daily Imaging
Ultrasound (BAT)
CT/ MRI
Helical Tomotherapy

25. Immobilization and Internal Organs
Immobilization by itself is insufficient to localize internal organs.
Respiration, tissue loss, and other factors play a role
Target organs can migrate significantly between treatment sessions
Location of Target Volume Must Be Verified Before Each Treatment
Optimal Solution: Use immobilization in conjunction with image guided localization (IGRT).
Immobilization by itself is insufficient to localize internal organs. Internal target organs can migrate significantly (1-2 cm) from their initial imaging location. Factors such as respiration, tissue loss, and physiological processes can play a role. Because of this, location of target structures must be verified before administering treatment. This can be done using immobilization along with IGRT to verify target organ location.
Examples:
Respiratory Gating – Timing the treatment beam with patient breathing cycles.
Fiducial Markers
BAT– Ultrasound technique (B-Mode Acquisition and Targeting)
Gold Seed Implant
IGRT/Tomotherapy – Planning, image guided localization and dose delivery on one machine.

26. Localization of Internal Organs in IMRT IGRT Techniques
Respiratory Gating
Camera driven system to match therapy to respiratory cycle
External Fiducial Markers
Therapy requires localization of fiducial skin markers
Daily BAT (B-Mode Acquisition and Targeting) Ultrasound Imaging
This is a 2-5 minute noninvasive procedure that is much easier to facilitate than daily CT scans.
Internal Fiducial Markers
Gold seed implants visible through imaging
Helical Tomotherapy
A CT like image that is produced in synchronicity to treatment.

27. Keep It Simple!
More often than not, it is a combination of two or more immobilization devices and techniques that will best help you achieve your desired outcome.

28. Common Setup Scenarios
Prostate
Supine
Prone
Head/ Neck/ Brain
Breast/Lung/Thorax
Now we’re going to review some common set up scenarios

29. Setup Scenario IMRT Prostate (Supine)
Most popular method.
Use a customized vacuum cushion or two-part foam (A popular and effective method is to immobilize from the lower gluteal fold to the heels encompassing the feet).
Lock your mold to the indexing treatment tabletops using lock down bars.
Use image guided systems, BAT, or seed implants to localize your target at the time of treatment.
Bill as Complex Treatment
Supine Positioning for Prostate IMRT
Preferred by both therapists and patients for ease of use and comfort.
Use customized vacuum cushion or 2-part foam (this is a complex treatment regimen).
Typical supine treatment plan includes: Full Bladder, minimal immobilization, daily BAT, higher daily dose, lower total dose, shorter treatment cycle.

30. Supine Prostate Setup With Indexed Vacuum Cushion
Example of indexed prostate setup for supine treatment.
Customized vacuum cushion, started at lower gluteal fold, encompassing feet. Use heels as reference point (hard point). Create a well defined mold by building up on the sides and between the legs. Properly made, there should be no question of patient’s position within the mold with each treatment.

31. Indexing Adaptors for Vacuum Cushions
Examples of indexing adaptors for vacuum cushions.
Vacuum cushions should be indexed to the treatment tabletop using adaptors and lockdown bars.

32. Setup Scenario IMRT Prostate (Prone)
Prone Positioning
Use a belly board, adjusting for patient size.
Position the patient comfortably dropping the belly through the abdominal opening.
Run your simulation, align and tattoo.
Immobilize the patient to the belly board with a sheet of thermoplastic.
Ease laser alignment by cutting holes in the thermoplastic.
Lock your belly board to the indexing treatment tabletop using lock down bars.
Internal immobilization can be used (ex: rectal balloon).
Use image guided systems, BAT or seed implants to localize target at the time of treatment.
Bill as Intermediate Treatment
Prone Positioning for Prostate IMRT
Typical prone treatment positioning: Empty bladder, extended course of treatment (9 weeks), lower daily dose, higher cumulative dose.
This can be either intermediate or complex treatment regimen depending on your use of customizable immobilization along with the belly board.
Internal immobilization with a rectal balloon and/or the use of image guided techniques can improve therapy delivery.

33. Prone Prostate Setup With Belly Board
Example of Bionix Belly Board showing typical prone positioning setup with prone face cushion, abdominal opening, and leg supports. Thermoplastic can be added for additional immobilization.

34. Prone Prostate Setup With Belly Board
Belly Board With Patient Customized Thermoplastic Mold Attached

35. Prone Prostate Setup Immobilization of Prostate Using Rectal Balloon
The prostate can move up to 6 mm daily in the A/P direction and 3-5 mm in the S/I direction
Prostate movement greater with patients in prone position
The use of a rectal balloon significantly reduces prostate motion by pushing the prostate against pelvic bone
The prostate can shift position significantly in response to respiration, bladder and rectal filling. Because of its proximity to the rectum, this movement can be limited by using a rectal balloon to compress the soft tissues surrounding the prostate, restricting its ability to migrate out of position.

36. Prostate Treatment Supine vs. Prone Comparison
Supine Treatment Plan:
Full bladder
Daily BAT
Higher daily dose
Lower total dose
Shorter treatment cycle
Preferred by therapists for ease of setup.
More comfortable for patients.
Complex coding for billing.
PRONE
Prone Treatment Plan:
Empty bladder
Lower daily dose
Higher cumulative dose
Extended course of treatment
Provides better fixation and displacement of the small bowels.
Typically requires more adjustments and patients have difficulties using belly boards.
Intermediate complexity coding for billing.
This slide compares the two treatment regimens for prostate IMRT. (read slide)

37. Setup Scenario IMRT Head/Neck/Brain
Setup patient with head in supine position
Use a carbon fiber headboard or head and shoulder system
Index the device to the treatment tabletop using lock down bars.
Use shoulder retractors or suppression system to properly position shoulders.
Use customized head and neck support and thermoplastic mask for each patient
Bite blocks can be molded into the thermoplastic for additional immobilization and rotational fixation
Example of customized head/neck support is the Moldcare pillow, ideal for IMRT.

38. Head/Neck/Brain Setup With Head and Shoulder System
Ideal for conformal treatments in a 360 degree arc. Increased support and stability in the neck and shoulders.

39. Head/Neck/Brain Setup With Head and Shoulder System
Registered shoulder suppression units for precise repositioning.

40. Specialized Headboard Systems For Head/Neck/Brain IMRT
Prone Tilt Attachment
45 Degree Tilt Attachment
SuProne Plus shows patient positioned prone with negative flexion allowing extension of the neck to eliminate neck folds.
SuProne Plus with 45 degree tilt attachment showing patient positioned supine with positive neck flexion.
Custom thermoplastic mask is used with both set ups.

41. Thermoplastic For IMRT
Thicker gauge or reinforced (3.2mm)
Greater immobilization and rigidity
Reinforced for greater rotational stability
More scatter with thicker thermoplastics
Higher likelihood for skin effects
3.2 mm thermoplastic needed for rigidity.
Reinforced thermoplastic gives greater rotational stability.
Greater scatter with thicker thermoplastics.
Higher likelihood for skin effects.

42. Setup Scenario IMRT Breast/Lung/Thorax
Position patient supine with arms raised above the head
Use a customized vacuum cushion or two-part foam with a butterfly board or extended butterfly board
Index the butterfly board to the treatment tabletop using lock down bars
Use respiratory gating or IGRT to account for patient breathing cycles
(read slide)

43. Breast/Lung Setup With Indexed Butterfly Board
Patient positioned supine on extended butterfly board, which is locked down to the treatment tabletop. Vaccum cushion customized to the patient and formed into the butterfly board. Patient grasps T-bar for added stabilization during treatment.

44. Breast/Lung Setup With Indexed With Breast Boards
Highly radiolucent/ Open grid panels allow flexible treatment
Indexable and Documentable
Multiple Angles for Patient Positioning
Narrow boards better for small bore CT scanners
Use with thermoplastic, etc. for complex billing
Breast Boards may also be used for indexed lung/ breast treatments.
Shown here is the Bionix Max3, which has a narrow outline to enable it to better fit small-bore CT scanners at higher treatment angles for treatment planning.

45. Basic Breast Setup in the Prone Position
Lock the Breast Board onto your couch using an indexable lockdown bar.
Position the patient by having them climb onto the board from the bottom end. Place the saddle into the most comfortable position, or remove completely if unnecessary.
Position the Breast Bridge so that the contra lateral breast rests comfortably out of the treatment field.
Position the face cushion into the most comfortable position for the patient. Note the labeled setting.
Use the Ruled Edge that runs along the base to align the patient for treatment.
Thermoplastic sheets may be used to immobilize the pelvic region for a complex treatment scenario.
If all indexing aspects of the board are utilized, and proper documentation is acquired, the breast will naturally fall into the same position everyday.

46. Buying Immobilization Devices
Obtain Price Quotes from Multiple Vendors.
This is a common practice, two or three different quotes may yield some unexpected results.
Be sure to inquire about Warranties, Accessories, Money Back Guarantees, and future Upgrades.
There are no industry standards, compare apples to apples.
Some items might come as a complete set, some might require many additional accessories
Use the devices before you invest.
Most manufacturers offer free Trial Evaluations or some kind of money back guarantee.
Take advantage of the in-service.
This will often lead to not only a free lunch, but also better pricing and a better relationship with your Representative.
(read slide)

47. Thank You!!