1. No category

RapidArc*
The Next Dimension in
Speed and Precision
Paperless Medical
Records: Two New Cancer
Centers Rely on ARIA
Treating Challenging
Cases at Stanford University
Cancer Center
CONTENTS O CTOB ER 2007
CENTERLINE
Centerline magazine is
published twice a year by
Varian Medical Systems,
http://www.varian.com.
Centerline welcomes letters to
the editor, contributions for
point-of-view commentaries,
and suggestions for articles.
Reprinting of Centerline articles
may take place with permission
from the editor. Address comments, contributions, inquiries
about reprints and permissions,
subscription requests, and
address changes to:
Varian Medical Systems
3100 Hansen Way, M/S MGM
Palo Alto, CA 94304-1038
Attn: Meryl Ginsberg
F E AT U R E S
Eclipse in Practice
D E PA RTM E NT S
6
At Australia’s University of Newcastle, RT
students use Eclipse™ software to help develop
the knowledge and skills they need to work in
clinical environments.
Treating Challenging Cases
News
9
[email protected]
ON THE COVER
* Pending FDA 510(k) approval;
not available for sale in the
United States at this time.
© 2007 Varian Medical
Systems, Inc. All rights
reserved.
Clinac, On-Board Imager,
Trilogy, Varian, and the Varian
Medical Systems logo are registered trademarks and Acuity,
ARIA, BrachyVision, DART,
Eclipse, GammaMedplus,
Implant View, PortalVision,
RapidArc, RPM, Smart
Segmentation, Tx, VariSeed,
and VariSource are trademarks
of Varian Medical Systems, Inc.
ExacTrac, iPLAN, and Novalis
are registered trademarks of
BrainLAB AG. The names of
other companies and products
mentioned herein are used for
identification purposes only
and may be trademarks or
registered trademarks of their
respective owners.
1
What multislice
did for CT scanning,
RapidArc™ delivery
will do for radiation
therapy. Varian’s
Corey Zankowski,
PhD, explains.
+1 650.424.6444
Varian’s new RapidArc™
delivery* will improve dose
conformity while significantly
shortening treatment times.
Cover photo by WeinbergClark Photography.
Point of View
Clinicians at the Stanford University Cancer
Center use Varian IGRT technologies to treat
lung and pancreatic cancer.
Research Collaborations
12
More than a quarter of
the presentations at a
recent AAPM meeting
featured research supported
by Varian or performed using
Varian technologies.
Paperless Medical Records
16
Two new comprehensive cancer centers are
operating without film or paper. Both designed
their processes and workflow around the ARIA™
oncology information system.
Focus on Service
19
In the second of a series on Varian services,
Centerline looks at how installation times for
IGRT upgrades and
new machines are
being cut in half.
ASTRO Round-Up
A look at the new capabilities Varian
showcased at the 2007 ASTRO meeting:
RapidArc, the iX line of HDR afterloaders,
updated VariSeed™ LDR brachytherapy
planning software, and the high-definition
multileaf collimator.
2
ARIA Demonstrated at ASCO
At a recent ASCO electronic health records
symposium, Varian was invited to demonstrate
the ARIA oncology information system.
4
Varian and BrainLAB Bundle
Radiosurgery Products
The new Novalis® Tx combines the most
successful Varian and BrainLAB radiosurgery
technologies for imaging, treatment planning,
and treatment delivery.
First IGRT School Held in UK
Varian and the Clatterbridge Centre for
Oncology kicked off a new set of IGRT
programs for European clinicians, physicists,
and radiographers.
Training Updates
4
5
21
Varian’s New RapidArc Delivery:
The Next Dimension in Speed and Precision
POINT OF VIEW
™
By Corey Zankowski, PhD
• Simultaneously modulate the shape of the
treatment aperture, the dose rate at each
gantry angle, and when necessary, the
gantry speed.
R
apidArc*, a major advance
this year from Varian Medical
Systems, will improve dose conformity while significantly shortening
treatment times. RapidArc will achieve
a physician’s treatment objectives better
than today’s best IMRT techniques—
two to eight times faster than our fastest
dynamic treatments can be delivered
today. What multislice did for CT scanning, RapidArc will do for radiation
therapy.
• Minimize the total monitor units required
to generate the optimal dose distribution.
• Minimize the treatment delivery time.
• Calculate the optimal plan in a clinically
useful time frame (less than 60 minutes).
Volumetric modulated arc therapy
RapidArc is a volumetric arc therapy that delivers a precisely
sculpted 3D dose distribution with a single 360-degree rotation
of the linear accelerator gantry. It is made possible by a treatment planning algorithm that simultaneously changes three
parameters during treatment: the rotation speed of the gantry,
the shape of the treatment aperture using the movement of
multileaf collimator leaves, and the delivery dose rate.
Volumetric modulated arc therapy differs from existing
techniques like helical IMRT or intensity-modulated arc therapy (IMAT). Helical IMRT treatments apply dose in thick overlapping slices that take more time to deliver. IMAT, which uses
five to seven concentric arcs to deliver a conformal dose distribution, takes up to five times longer to deliver than a treatment
using RapidArc, which delivers dose to the whole volume rather
than slice by slice.
Although it represents a major advance in radiotherapy
treatment technology, RapidArc is easy to implement. It
requires no major process changes from the physician, physicist, dosimetrist, or therapist, as the steps for planning and
delivering treatments are virtually unchanged.
From funded research to product roadmap
Varian began looking for different ways to deliver a single-arc
IMRT treatment more than five years ago. Our objective was to
treat the tumor as conformally as possible in the least amount
of time, while being extremely efficient in the amount of radiation dose used. Our requirements were stringent:
• Use nearly every degree in a 360-degree arc to provide
the best chance of finding the optimal dose distribution
for the patient.
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Some early solutions gave us the dose distributions we needed, but they took too long to
plan. Other solutions required multiple arcs and
isocenters, which took too long to deliver and were too complicated to be practical. Work by Cedric Yu, DSc, at the University
of Maryland demonstrated that single-arc IMRT could equal or
exceed the target volume coverage achievable with conventional
multiple-field IMRT. Finally, thanks to some important innovations by physicist Karl Otto, PhD, as well as productive, sponsored research projects at the British Columbia Cancer Agency
and the University of Maryland, we now have an efficient, accurate, elegant treatment planning algorithm that meets all of our
requirements.†
The new RapidArc planning algorithm carefully exploits
many of the characteristics of Varian’s modern linear accelerators and multileaf collimators, including:
• Leaf interdigitation, which is uniquely possible with a
Varian multileaf collimator
• Varian’s dynamic “sliding window” approach to beam
shaping
• Varian’s patented “gridded gun,” which makes it possible
to vary the dose rate as a function of the gantry angle
Varian sponsored the RapidArc research and development
effort with a primary goal of improving clinical outcomes.
In the process, we discovered that we could improve dose
conformity and simultaneously improve treatment efficiency
significantly, as RapidArc delivery is anywhere from two to
eight times faster than was possible before. We are pleased to
have introduced this exciting new development at this year’s
ASTRO meeting in Los Angeles. ✺
Corey Zankowski, PhD, is senior director of software systems marketing at
Varian Medical Systems.
* Pending FDA 510(k) approval; not available for sale in the United States at this time.
† Researchers Karl Otto, PhD, James Morris, MD, and Tom Keane, MD, of the British
Columbia Cancer Agency, and William Regine, MD, and Cedric Yu, PhD, of the
University of Maryland Cancer Center, contributed to this project through research
funded in part by Varian Medical Systems.
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1
ASTRO ROUND-UP
ASTRO Round-Up
Varian exhibited a range of new technologies at this year’s meeting of the American Society for Therapeutic
Radiology and Oncology (ASTRO), held October 28 through November 1, 2007, at the Los Angeles Convention
Center. On display were Varian’s new RapidArc™ delivery technology*, a high-definition multileaf collimator for
radiosurgery, and updated tools for planning and delivering LDR and HDR brachytherapy treatments.
RapidArc Delivery
RapidArc* is a major advance
that will enable clinicians to
improve dose conformity and
significantly shorten treatment
times. RapidArc delivers a complete intensity-modulated radiation treatment during a single
360-degree rotation of the linear accelerator gantry around
the patient.
anatomical sites,” says William F.
Regine, MD, professor and chairman of the Department of
Radiation Oncology at the
University of Maryland School of
Medicine and chief of radiation
oncology at the University of
Maryland Medical Center, where
research into single-arc dose
painting has been taking place
In this prostate cancer treatment plan, volumetric modulated
arc therapy shows superior conformality in the superior-inferior
for
some time. “Varian’s technolRapidArc is made possible by a
direction when compared to helical IMRT.
ogy for image-guided radiation
powerful new software algotherapy was technically ahead to
rithm that can control changes
begin
with,
and
now
Varian
is
adding
efficient arc therapy that
in three parameters simultaneously: 1) the speed of the gantry
can
be
delivered
in
multiple
planes,
i.e.,
volumetrically. With the
rotation, 2) the shape of the aperture created by the movement
same
technology
we
use
to
deliver
noncoplanar
treatments, we
of multileaf collimator (MLC) leaves, and 3) the dose delivery rate.
can now also offer very fast arc therapy. It’s a testament to what
“The algorithm is designed to generate highly conformal dose
can happen when the thought leaders in industry work together
distributions while taking advantage of the specific capabilities
with innovative clinical researchers. The result is something that
of the Varian linear accelerator,” says Karl Otto, PhD, medical
makes a practical difference to patient care and to our ability to
physicist, British Columbia Cancer Agency (BCCA), a researcher
offer whatever is best for each of our patients.”
and major contributor to RapidArc R&D efforts. “The speed of
According to Cedric Yu, DSc, the Carl M. Mansfield, MD, professor
MLC motion, gantry rotation speed, and dose rate are all used
of radiation oncology at the University of Maryland Medical
by the algorithm to ensure the treatment is delivered efficiently
Center and another important contributor to RapidArc research,
and accurately.”
his studies of single-arc IMRT have shown it to be equal to or betVarian researchers have found that RapidArc dose distributions
ter than multiple-field IMRT in terms of target volume coverage
are fast to deliver, and they are equivalent to or better than conand normal tissue sparing. He found that a single arc can deliver
ventional IMRT or helical IMRT for a variety of clinical sites. In
essentially similar dose distributions compared with IMRT plans
one example, a multitarget cancer of the nasopharynx, RapidArc
that incorporate as many as 36 fields.
plans were found to be equivalent or better at target coverage
“Clinicians everywhere are rapidly adopting online IGRT techfor all targets, and superior in protecting critical structures
nologies like Varian’s On-Board Imager® system,” BCCA’s Otto
including the spinal cord, brain stem, eyes, optic nerve and chipoints out. “Patients benefit from a focus on accurate patient
asm, parotid glands, and brain. In this test, the RapidArc delivery
positioning through daily imaging. RapidArc is extremely time
took only 110 seconds and used only 585 monitor units (MUs).
efficient, which contributes to patient comfort. It is likely that
Other tests showed that even complex RapidArc treatment plans
we
will see image-guided arc therapy sessions take less than 10
can be delivered in less than 2.5 minutes, with fewer than 750
minutes,
including imaging and treatment.”
MUs. In comparison, Varian’s best IMRT treatments, delivered one
field at a time, require approximately one minute per field to
deliver, while the average multislice helical IMRT treatment
requires 10 to 15 minutes.
“Previous approaches to arc IMRT therapy have been restrictive.
Some are limited by machine design, and deliver treatments
in the axial plane only, making it impractical to treat certain
Varian customers who adopt RapidArc will gain this new clinical
capability without sacrificing the ability to deliver other forms of
treatment if needed. A Trilogy® or Clinac® iX accelerator outfitted
to deliver RapidArc can still deliver static fields, noncoplanar
treatments, electron therapy, and conventional forms of IMRT,
IGRT, SBRT, and SRS. ✺
* Pending FDA 510(k) approval; not available for sale in the United States at this time.
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iX Line of HDR Afterloaders
Also at ASTRO, Varian introduced the iX
line of afterloaders, advanced devices that
simplify high-dose-rate (HDR) brachytherapy delivery and optimize treatment. The
new iX systems are currently being
shipped to customers and are already in
operation at a number of sites.
LEFT
BELOW | A screen capture from the VariSeed 8.0
treatment planning system.
At the heart of the iX afterloaders is new
Windows-based control software, common to both the VariSource™ iX and
GammaMedplus™ iX afterloaders, the
computer-controlled devices used for
delivering the radiation sources. The new
software integrates seamlessly with
Varian’s BrachyVision™ treatment planning system.
“We have introduced a world-class product with a console that integrates with all
our brachytherapy delivery products and
software, making it easier to use and
more straightforward to plan treatments,”
says William Hyatt, head of Varian
BrachyTherapy. “It’s a major leap forward
in brachytherapy treatment delivery.
“We recognize the unique challenges of
delivering high-dose-rate treatments.
Time pressure is high and patients are
anxious, while the importance of getting
it right is paramount. That is why we’ve
worked with customers, engineers, and
software developers to produce an afterloader control interface that is both intuitive and simple to use.” The product’s
interface was developed in conjunction
with IDEO, a leading international industrial design company.
“The iX has really improved the situation
for us and our patients, as it is much more
logical and gives you a better overview of
the treatment’s status,” says Peter Niehoff,
MD, brachytherapy consultant at
University Hospital Kiel, in Germany—the
first hospital in the world to treat patients
using the new system.
| The VariSource iX HDR afterloader.
According to Niehoff, the iX system makes
it easier for his team to alter the treatment plan once treatment is under way
and to program the afterloaders to make
changes. “If you deliver the first fraction
and then need to change the plan, it’s
vital that you can easily access this information,” he says. “Some of these treatments are extremely complex—just
recently we did an interstitial chest well
treatment involving 16 channels and 300
dwell positions—so anything that makes
alterations more straightforward is
extremely valuable.”
His colleague, chief brachytherapy physicist Frank-Andre Siebert, PhD, says the iX
system is so straightforward that even
inexperienced operators can handle it
with ease. “As a test,” he says, “I asked a
young physicist colleague who is not
experienced in brachytherapy to set up
and plan a typical prostate patient using
a dummy. It took him 15 minutes to create a perfectly workable treatment.” ✺
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VariSeed LDR Brachytherapy
Planning Software
VariSeed™ 8.0, an updated version of
Varian’s market-leading brachytherapy
seed planning software, incorporates new
features that give clinicians more ways to
define and visualize seed placements
when planning and delivering low-doserate (LDR) brachytherapy treatments for
prostate cancer.
“The new features provide even better
visibility of the positions of individual
seeds in permanent seed implants,” says
Rebecca Claydon, software product manager with Varian BrachyTherapy. “Based
on feedback from urologists, VariSeed 8.0
facilitates the planning of prostate seed
brachytherapy treatments by biopsy section, so that a localized boost can be delivered to a targeted region of the prostate.”
VariSeed 8.0 offers brachytherapy physicists new and improved contouring tools,
including the ability to contour in the
3
Among the new features is a tool that
creates a digital reconstruction of the CT
image and makes it much simpler to
define the seed placement. A typical
permanent seed implant involves up to
120 radioactive seeds, each the size of a
grain of rice.
There are more than 1,200 hospital sites
worldwide using more than 1,600
Varian VariSeed software systems for
guiding the placement of permanent
prostate seed implants. Use of this technique alone or with external beam
radiotherapy is increasing for patients,
including about 60,000, or one third, of
the U.S. men who are diagnosed annually with prostate cancer. ✺
High-Definition MLC
Varian has received FDA 510(k) clearance for a new high-definition MLC. The
new HD120 MLC doubles the resolution
of Varian’s most precise MLC by reducing the width of the central leaves to
just 2.5 millimeters.
According to Calvin Huntzinger, MS,
marketing and engineering manager for
Varian Surgical Sciences, the HD120 MLC
collimator will be included with the new
Novalis® Tx suite of radiosurgery products that Varian is teaming up with
BrainLAB to offer. Designed for extreme
durability, the new MLC offers improved
dose delivery characteristics, including a
steeper dose fall-off gradient.
“This new high-definition multileaf collimator builds on Varian’s widely recognized accomplishments in advancing
MLC technology,” says Huntzinger. “It
underscores our commitment to meeting the unique needs of clinicians offering stereotactic radiosurgery and
stereotactic body radiotherapy.” ✺
4
NEWS
ASTRO ROUND-UP
sagittal and coronal planes. Contouring
the urethra has been simplified by the
introduction of the Structure Sweep,
which is also available in the VariSeed
Implant View™ module for interactive
seed placement and dosimetry.
ARIA Demonstrated at ASCO
EHR Symposium
Varian and BrainLAB Bundle
Radiosurgery Products
Earlier this year, Varian was one of
seven vendors selected to participate
in the American Society of Clinical
Oncology (ASCO) Electronic Health
Records (EHR): 2007 Oncology
Symposium held September 19–20 in
Dallas, Texas. Varian showcased the
company’s ARIA™ oncology information
system, a comprehensive EHR for managing patient information in cancer
treatment centers as well as radiation
and medical oncology departments.
In a move to offer superior noninvasive
treatment options, Varian and BrainLAB
have teamed up to create Novalis® Tx,
bringing together the most successful
radiosurgery technologies from both
companies for imaging, treatment
planning, and treatment delivery.
“We were honored and pleased to be
among the vendors invited to participate in the symposium,” says Maureen
Thompson, senior director for Varian’s
oncology information systems. “Varian’s
ARIA system is one of the most comprehensive, robust EHR solutions available.
It is unique in its depth of clinical support for both radiation and medical
oncology treatment processes. In addition, we continue to enhance our oncology information system capabilities,
focusing on quality measures and outcomes relevant to specific disease sites,
and to track compliance with specific
treatment protocols. We believe that an
oncology-specific EHR can improve the
quality of cancer care.”
At the symposium, Varian and the other
vendors conducted oncology-specific
product demonstrations based on scenarios provided by ASCO. “Buying an
EHR is a major decision for an oncology
practice,” says Ken Hotz, EHR product
manager for Varian. “These software
tools become a part of the clinic’s culture and way of life. Those who attended the symposium came away with a
very good understanding of the products and how they compare with one
another.” ✺
Novalis Tx includes Varian’s Trilogy® Tx
linear accelerator and the new HD120
multileaf collimator, which offers 2.5mm leaves for finer beam shaping. The
ultraprecise Novalis Tx radiosurgical
instrument will use a variety of standard and configurable options, including Varian’s On-Board Imager® device,
the BrainLAB ExacTrac® X-Ray 6D roommounted X-ray imaging system, the
BrainLAB iPLAN® treatment planning
software, and Varian’s Eclipse™ treatment planning and ARIA™ information
management software.
“This powerful platform enables both
companies to offer radiation oncologists, neurosurgeons, and other medical
specialists the sharpest knife available
for radiosurgery,” says Tim Guertin,
president and CEO of Varian Medical
Systems. “This product introduction is
a natural extension of a relationship
that has been in place since 1996, when
BrainLAB and Varian incorporated linear
accelerator and multileaf collimator
technologies to create the Novalis line
of radiosurgery products.”
“Building upon our long-time relationship with Varian and the strengths of
both organizations, Novalis Tx combines
the most powerful and advanced capabilities available on the market today,”
says Stefan Vilsmeier, president and
CEO of BrainLAB. “More versatility and
efficiency will mean new hope for more
patients.”
The Novalis Tx offers the widest range of
treatment options for the largest number of indications, including malignant
and benign lesions, brain metastases,
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| O C TO B E R 2 0 0 7
The first two days consisted of presentation sessions, while the third day focused
on clinical sessions at the hospital. This
format will be followed for subsequent
schools.
“Varian approached me following my
presentation at last year’s ESTRO meeting
to ask if we could offer an IGRT School for
departments across Europe,” says Angela
Heaton, clinical specialist radiographer at
CCO. “We have made the On-Board Imager
a routine part of our treatments on our
linac and I believe we are using it more
than anyone else in Europe.”
The Novalis Tx suite
of radiosurgery
products.
arteriovascular malformations, and functional lesions. It features the highest dose
delivery rates in the industry, dynamic
beam shaping, and frameless patient
positioning for more rapid, effective, and
comfortable treatments. Unlike other
radiosurgical devices, which are limited
to a 6 million electron volt (MEV) energy
level, the Novalis Tx allows multiple beam
energies from 6 to 20 MEV for treating
deep-seated tumors and sparing surrounding healthy tissue more effectively.
Clinics should be able to treat twice the
number of patients per day than with any
other radiosurgery system on the market.
First European IGRT School
Held in UK
Varian sponsored its first European IGRT
School at the end of September at the
Clatterbridge Centre for Oncology (CCO)
in Wirral, UK.
Clinicians, physicists, and radiographers
from hospitals in Italy, Russia, Norway,
Spain, and Scotland attended the threeday event, taught by clinical experts at
CCO, one of the earliest adopters of
Varian’s On-Board Imager® device for IGRT.
According to Julie Massey, head of radiotherapy, “This recognizes our achievements in establishing IGRT techniques
within a routine clinical setting at
Clatterbridge Centre for Oncology. We’re
delighted to work closely with Varian and
to be able to offer this school to such a
wide geographical area.”
The schools will be run four times a year,
and will be offered to all treatment centers purchasing the On-Board Imager kV
imaging system. The next school takes
place December 6–8, 2007, and 2008 sessions have been scheduled for dates in
February, June, October, and December. ✺
The Novalis Tx offers the most comprehensive image-guidance system available,
including Varian’s machine-mounted 3D
CT scanner with 2D radiographic and fluoroscopic imaging capability as well as
BrainLAB’s room-mounted X-ray imaging
system for real-time imaging and motion
management. Coupled with BrainLAB’s
6D robotic couch, the system offers an
extremely fast and accurate solution for
setting up and verifying proper patient
position during treatment.
The treatment planning and information
management software presents clinicians
with the fastest, most user-friendly and
versatile platform for managing, planning, and delivering radiosurgery. ✺
Clinicians who attended the first Varian-sponsored IGRT School in Europe.
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5
Eclipse in Practice
at the University of
Newcastle, Australia
By Shane Dempsey,
University of Newcastle
A
With an intake of around
50 students, the program
educates graduates to work
in RT departments
across all elements of
practice: simulation,
planning, and treatment.
t the University
of Newcastle in
New South
Wales, Australia, a
bachelor’s degree program teaches students
to work in radiation
therapy departments
across all elements of
practice. By training
students on Version 8 of Varian’s Eclipse™
treatment planning software, the university
helps ensure that graduates have the knowledge and skills to work effectively in clinical
environments.
Among University of Newcastle’s more than 20,000 students is a cluster of future radiation therapists. The university’s School of Health Sciences runs a three-year, six-semester
bachelor of medical radiation science (radiation therapy) program on its largest campus in the city of Newcastle.
With an intake of around 50 students, the program educates
graduates to work within RT departments across all elements
of practice: simulation, planning (dosimetry), and treatment.
While the program teaches professional skills at the university,
students also gain around 1,000 hours of workplace experience
by attending a variety of clinical sites over the three years of the
program. Clinical affiliates include all 19 RT departments in
New South Wales and several departments in Tasmania and
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Western Australia where RT
training does not exist.
The program has a strong
commitment to ensuring that
students have the knowledge
and skills to work effectively
and ethically while on clinical
placement. Until recently, the
program had an aging 2D
planning lab, and there was
a need to commission a new
lab capable of training students in 3D-CRT and IMRT
treatment approaches. The university looked at how this could
best be done. The solution was a partnership with Varian and
the establishment of a 3D planning lab with a network of 10
Eclipse workstations.
Better tools for teaching
There were many reasons for selecting the Varian Eclipse
system for treatment planning. Eclipse would allow for conventional, 3D conformal, and IMRT plans to be developed.
We wanted to ensure that the planning system could teach
students basic conventional concepts such as physical wedges
and manual shielding by slice-by-slice beam configuration and
dose analysis. This would allow students to understand the
underpinning clinical concepts of RT. With the software’s 3DCRT functions, we would be able to teach developments such
as MLC beam shaping rather than shielding, dose volume histogram (DVH) analysis as an aid to dose and volume analysis,
and asymmetric and noncoplanar techniques. With IMRT, we
would be able to teach both forward-planned step-and-shoot
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RT students at Australia’s University of Newcastle. Photo courtesy of the University of Newcastle.
planning using the field-in-field functionality of Eclipse, as
well as inverse-planned IMRT using dose volume and costfunction optimization.
Eclipse allows for manual and automated methods of dose
volume determination. With Eclipse, we would be able to
teach slice-by-slice volume outlining using manual methods;
this would allow students to understand the relationships of
volumes between slices and between structures. We would be
able to use automated tools such as Flood Fill, coupled with
the density settings and the Volume Wizard, to autocontour
structures. With the postprocessing tools and Boolean functions, we could teach students to construct full and partial volumes more quickly. Eclipse allows for overlapping structures
and creating new structures by shrinking or expanding in all
directions from the margins of existing structures.
Eclipse has a great range of plan assessment tools, such as
a means of allowing DVH to remain active in the model view
while you plan and optimize. The plan comparison DVH
functions allow for multiple plans to be compared on a single
DVH. The Dose Color Wash display gives students a view of
the beams and structures through a transparent dose cloud.
Recently, final-year students developed a range of prostate
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plans on the same data set using early-1980s-standard four
fields (10x10x10 cm fields with small postcorner shielding for
the rectum), a five-to-seven-field 3D-CRT approach, and a
multifield inverse-planned IMRT plan. The dose color wash
across the adjoining pelvic structures starkly demonstrated the
advantages of each plan over the preceding plan.
In our selection of Eclipse, an added advantage was that the
networked, Windows-based environment is well supported by
the university’s information technology division, and the university has a partnership with Dell for hardware support. The
university also has great support from the Varian office in
Sydney (about two hours away). This allowed the networked
Eclipse environment to be set up to suit both Varian’s requirements and the university’s needs.
Immediate clinical relevance
Eclipse is used widely across Australia and therefore the training of students has immediate clinical relevance in those centers. The system allows students to set up treatments online in
RT Chart, so students are being trained to work within the
paperless environment that is becoming increasingly common
in treatment centers.
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7
Eclipse is used widely across
Australia and therefore the
training of students has immediate clinical relevance in
those centers.
In February 2007, the staff started using the system and
developing the structure that students would work with during
the upcoming university year. In March, around 60 secondand third-year students were let loose on the system.
In the eight months since they were introduced to Eclipse,
students have developed 3D-CRT plans using manual outlining and manual beam-shaping methods, 3D-CRT plans using
automated methods for contouring all outlines and structures,
and automated beam shaping and isocenter placement using
beam fitting, shaping, and aligning functions. The postprocessing and Boolean tools have been extremely popular and
easy-to-use tools to support contouring and volume creation.
The students have developed a range of IMRT plans using
step-and-shoot, field-in-field methods, and then compared
these outcomes to inverse-planned, DVH-optimized plans.
Students have approved plans in RT Chart and scheduled
treatments. All these activities mean that the University of
Newcastle’s graduates will be prepared for emerging clinical
practice.
RT students practice developing treatment plans using Eclipse
software. Photo courtesy of the University of Newcastle.
All in all, our experience with Eclipse has been fantastic.
Our system of choice has worked well for us and has been
extremely stable under the conditions of use of 60 students.
Even with as much fun as we are having with the current system, which will remain clinically relevant for years to come, I
look forward to future releases and to exploring what else can
be achieved with things such as gantry-optimized IMRT. ✺
Shane Dempsey is program director for the University of Newcastle’s
bachelor of medical radiation science (radiation therapy) program.
Eclipse: A Spectrum of Advanced Features
The latest version of Eclipse incorporates
many features that make treatment
planning better and faster, including:
• Beam-angle optimization
• Smart Segmentation™ automatic
contouring
• Planning on 4D data sets for motion
management
• Library of disease-specific clinical
planning protocols and treatment
plan templates
• Interactive fluence optimization
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| O C TO B E R 2 0 0 7
• Remote planning capabilities
• Fast 3D image registration for
matching cone-beam CT images
with planning CT images
• Dynamic adaptive radiotherapy
(DART™) planning based on up-tothe-minute image information
• The AAA dose-calculation algorithm
for planning treatment in heterogeneous areas of the body
• The electron Monte Carlo algorithm
for planning electron treatments
Stanford Doctors Treat Challenging
Cases with Varian IGRT
PET/CT and 4D-CT images—illustrating respiratory-gated treatment at the exhale phase of breathing—differentiate the tumor from the surrounding
collapsed lung (atelectasis) and map the extent of tumor motion. Images courtesy of Stanford University Cancer Center.
By Nancy Heifferon
C
linicians at the Stanford University Cancer
Center have been pulling out all the stops
to find optimal ways of using Varian technology to treat moving tumors close to sensitive
structures. Using a Trilogy® machine outfitted
with an On-Board Imager® device and a Real-Time
Position Management (RPM™) system for gating
and motion management, they are treating difficult cases throughout the body.
More flexibility for treating lung cases
Billy W. Loo, Jr., MD, PhD, is program leader in thoracic radiation oncology at the Stanford Cancer Center. Advances in imaging and tumor motion management are giving him the flexibility he needs for treating challenging lung tumors.
When treating lesions in the lung, it can be difficult to deliver high enough doses to a targeted lesion because of the limited
tolerance of normal tissues in the lungs, esophagus, heart, and
spinal cord—especially in frail patients with low lung reserve.
“The more precise and conformal we can be, the better the therapeutic index is, in terms of delivering more dose to the tumor
while limiting the dose to surrounding tissues,” explains Loo.
CENTERLINE
IMRT for a stage III tumor
Take the recent case of a man in his late 50s with a prior left
pneumonectomy for early-stage lung cancer, presenting with a
new stage III non–small cell lung cancer in his right lower lobe.
Dynamic 4D-CT imaging demonstrated that the new primary
tumor, which sat close to the diaphragm, moved nearly 3 centimeters as he breathed. With limited healthy lung remaining,
he was ineligible for further surgery and also at high risk for
lung injury from conventional radiation therapy fields.
Using respiratory-gated PET/CT and 4D-CT scans to pinpoint the location of metabolically active lymph nodes, distinguish the tumor from surrounding collapsed lung tissue, and
map the motion of the tumor throughout the respiratory cycle,
the Stanford team was able to design a very conformal IMRT
treatment plan with respiratory gating. Loo uses respiratory gating selectively for lung treatments. In this case, the benefit to the
patient, in terms of the lung volume spared, clearly outweighed
concerns about the complexity that gating introduces to the
treatment.
For respiratory-gated treatments, Loo uses a Trilogy machine
with the On-Board Imager device. Because the patient was also
receiving chemotherapy, Loo prescribed a total radiation dose
of 70 Gy, delivered in 35 daily fractions of 2 Gy over 7 weeks.
Each day, the radiation therapist took kV images with the OnBoard Imager to set up the patient for treatment according to
proper bony anatomy alignment. Then a set of moving images
| O C TO B E R 2 0 0 7
9
was taken with the device in fluoroscopic mode. “With real-time fluoroscopic images of tumor motion at the
time of treatment, we have the flexibility on the spot to adjust the respiratory gating to ensure that the
beam comes on when the internal
anatomy is in proper position,”
explains Loo. This patient tended to
be fairly consistent in his breathing,
but not all patients are, cautions
Loo. “Daily position verification and
daily pretreatment fluoroscopic verification ensure the reproducibility of
the internal anatomy compared to
the plan.”
On short-term follow up, this
patient is doing well clinically.
“Emerging data suggests that early
response to treatment is a prognostic
indicator,” says Loo. “I am encouraged to see a good tumor response
indicated by both PET and CT follow-up imaging.”
that up and compensated for it was
with cone-beam CT imaging between
treatment fields,” says Loo.
“With real-time fluoroscopic
images of tumor motion at the time
of treatment, we have the flexibility
on the spot to adjust the respiratory
gating to ensure that the beam
comes on when the internal
anatomy is in proper position.”
Billy W. Loo, Jr., MD, PhD, Stanford Cancer Center
Pulmonary radiosurgery for a small metastasis
In a second case, a young man in his 30s with chondrosarcoma,
a rare, slow-growing cancer of the cartilage, had a single 1-cm
lung metastasis in the right lower lobe. He had already been
subjected to repeated thoracotomies for previous metastatic
tumors in the lungs. Although this tumor was resectable, concerns about further loss of lung reserve and the man’s ability to
tolerate the rigors of another major operation made it reasonable to consider stereotactic radiosurgery. The local control rate
for small peripheral tumors like the one in this case is over 90
percent with pulmonary radiosurgery.
Following Stanford’s pulmonary radiosurgery protocol, Loo
treated this patient with 25 Gy in a single fraction, using the
Trilogy machine. The patient was a good candidate for this
treatment option because his tumor demonstrated relatively little respiratory motion on 4D CT. This meant Loo could expect
reasonable visualization of the small tumor without fiducial
markers, using the On-Board Imager’s cone-beam CT capability. “Though we routinely use fiducial markers for pulmonary
radiosurgery, we wanted to avoid the invasive procedure in this
case,” explains Loo. “The cone-beam CT option gives us this
additional flexibility.”
Over the course of the hour-long treatment, the patient’s
breathing pattern gradually changed, growing deeper on inhalation and shallower on exhalation, probably due to the discomfort of immobilization. “The only way we could have picked
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Two years ago, it would have been
difficult or even impossible to treat
either of these patients adequately and
safely with radiation therapy because
of the lack of needed precision. “We
can do a lot more with radiotherapy
today because new technologies enable
us to be more precise in defining the
tumor extent and location, characterizing its motion, and designing plans
with appropriate margins that allow us
to give an adequate dose of radiation
to the tumor while sparing surrounding structures,” says Loo. “4D IGRT
fills in a key piece of the puzzle by
enabling us to verify that these very
complex treatments are actually being
delivered according to plan.”
Targeting locally advanced
pancreatic cancer
Other clinicians at Stanford are combining a single fraction of radiotherapy (stereotactic body radiotherapy, or SBRT) with gemcitabine chemotherapy to investigate
their combined effects on locally advanced pancreatic cancer.
Early results with the first 20 patients treated on Trilogy are
encouraging. The exquisitely precise targeting needed to deliver
high-dose radiation while sparing the surrounding liver, stomach, and bowel is made possible by the latest advances in imageguided radiation therapy.
Pancreatic cancer is a deadly disease with few effective treatment modalities. Every year in the United States, more than
30,000 patients are newly diagnosed and a similar number of
annual deaths are attributed to this disease. Historically, surgery
is the only option associated with long-term survival. However,
only 15 percent of newly diagnosed patients have surgically
resectable tumors. The majority of pancreatic cancer patients
have metastatic or locally advanced disease—unresectable
tumors that have spread beyond the pancreas. With current
treatment methods, the median life expectancy for these
patients is six to nine months. Clinical trials to date have shown
that gemcitabine is the single most effective chemotherapy in a
spectrum of systemic agents with limited activity in pancreatic
cancer. Conventionally fractionated radiotherapy, in combination with chemotherapy, has been shown to improve survival
and is useful in palliation of pain and preventing gastric
obstruction.
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Double-teaming a
challenging disease
with spiral CT scanning; 1.25-mm
cuts provide maximum resolution of
the tumor. An FDG-PET scan shows
the metabolic hot spots in the tumor.
Additionally, 4D-CT scanning is done
to account for respiratory-associated
tumor motion. According to Koong,
pancreatic tumors can move as much
as two to three centimeters during the
respiratory cycle.
But could an optimal combination of
SBRT and chemotherapy make a difference? That is the question that the
Stanford team is attempting to
answer in a phase II clinical trial.
“Studies from the 1980s suggested
some benefit from this dual
approach,” says Albert Koong, MD,
PhD, of the Stanford Cancer Center’s
Department of Radiation Oncology.
“However, local control of the tumor
was highly variable in these studies.
While it was difficult to determine
local control before CT scanning was
widely available, most studies suggest
that 25 to 50 percent would fail
locally after the radiation therapy.”
“Our medical oncology colleagues
are starting to use targeted
therapeutics routinely, but
radiation is the original and
ultimate targeted therapy.”
“We fuse all these images together,
reconstruct the anatomic location of
the tumor during the respiratory
cycle, and correlate the location of
the tumor with the metabolic activity
seen on the FDG-PET scan,” explains
Koong. “This gives us the gross tumor
volume, to which we add 2 to 3 mm
for the planned treatment volume.”
Albert Koong, MD, PhD, Stanford Cancer Center
In these earlier studies, the total
radiation dose was delivered in a
course of 1.8-to-2-Gy fractions in
either a split course or continuous manner for 4 to 6 weeks.
Today, the standard radiotherapy is given in a similar manner
with concurrent 5-fluorouracil chemotherapy. “Some institutions such as the University of Michigan have pioneered an
approach where they have been able to give systemic gemcitabine with an abbreviated course of radiotherapy over three
weeks instead of six weeks,” says Koong. “They have been relatively successful with that approach.”
Under the Stanford protocol, patients newly diagnosed with
locally advanced pancreatic cancer receive a total radiation dose
of 25 Gy all in one fraction. The radiotherapy is delivered
sequentially between the first and second cycle of gemcitabine
chemotherapy. Integrating SBRT with chemotherapy in this
manner allows full dose systemic therapy without compromising the local radiation dose intensity.
Image guidance for precision
Stanford is able to safely escalate the radiation dose by using
advanced IGRT technologies such as Varian’s On-Board Imager
and RPM system, which are designed to work in an integrated
manner with the Trilogy machine. “In our approach,” says
Koong, “we have the ability to target these tumors more precisely than we ever have in the past.”
The process is a complex one. Preparing the patient and
planning the treatment takes one to two weeks. Gold seed fiducial markers, three to five of them, are placed by CT or endoscopic guidance into the tumor and surrounding pancreas. A
body mold is made to immobilize the patient during the treatment. The pancreas is imaged in arterial and venous phases
To deliver the planned singlefraction treatment, Stanford uses an
IMRT approach with respiratory gating to conform the radiation delivered to the exact location and
shape of the tumor. This approach enables clinicians to reduce
the treatment margin and maximally spare the surrounding tissue from radiation toxicity.
At the time of treatment, the radiation therapist takes both
2D and fluoroscopic images with the On-Board Imager to establish correct alignment and confirm that the marker seeds come
into the right range when the radiation beam is turned on, typically during exhalation phase. The imaging process is repeated
for each beam angle, and patient position is adjusted as necessary. “For each beam angle, using the kV imaging mode, we can
see where the fiducials are in relation to bony anatomy,” says
Koong. “Then we take fluoroscopic images to give us a dynamic
picture of what’s really happening during respiration. When
such a high radiation dose is involved, we need this additional
level of precision so that we can be sure that we are delivering
the treatment as planned.”
The ultimate in targeted treatment
Eighteen months into the clinical trial, the early findings are
trending positive: no significant acute GI toxicities and only one
local failure to date.
“As systemic therapies improve, it becomes more important
to integrate these newer therapies with targeted radiotherapy
approaches,” says Koong. “Our medical oncology colleagues are
starting to use targeted therapeutics routinely, but radiation is
the original and ultimate targeted therapy. Advances in imaging
techniques will parallel the advances in radiotherapy by improving our ability to target tumors.” ✺
Nancy Heifferon is a freelance healthcare writer.
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11
Varian Research Collaborations
on Display at AAPM
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By Lynn Yarris
T
he history of Varian Medical Systems is
steeped in scientific and engineering
research: the company can trace its roots
back to the invention of the klystron, the first compact source of high-powered microwaves, by the
brothers Russell and Sigurd Varian. This tradition
of research continues today, as was evident at the
forty-ninth annual meeting of the American
Association of Physicists in Medicine (AAPM),
which was held July 22–26, 2007, at the
Minneapolis (Minnesota) Convention Center.
More than 250 papers and posters, or better than
a quarter of all the presentations, were about
research that was either directly supported by
Varian or performed using Varian technology.
“Varian continues to focus on increasing our level of
collaborative activity that can help deliver real solutions
to the problems impacting clinical cancer care,” says
Michael Sweitzer, the manager of Varian’s research
collaborations. “While we are seeing
other companies cut back on their
development efforts, Varian is
expanding both the breadth and
depth of our research collaborations.”
Radiation physicists from the Medical Center at the
University of California, San Diego, delivered a paper describing their initial experience using a single-isocenter, singlefraction IMRS technique to treat patients with multiple brain
metastases. Ten patients were treated using an IMRT-based
treatment in which patient setup and target localization during
treatment were carried out with Varian’s frameless localization
system. The results showed that 8 to 12 fixed beams properly
selected with a single isocenter were sufficient to achieve good
dose coverage and organ sparing. The treatment time was less
than 60 minutes to deliver dose of 16 to18 Gy. The authors
concluded that IMRT-based SRS treatment of multiple brain
metastases or large irregular lesions saves treatment time and
gives the benefits of dose conformity and organ sparing, easy
plan QA, and patient setup verification.
Researchers from the M.D. Anderson Cancer Center
reported the use of image-guided stereotactic body radiotherapy (IG-SBRT) for treatment of spinal tumors using
cone-beam CT for daily pretreatment imaging. A spine
phantom was used to study the feasibility and accuracy of this approach before a patient was successfully
treated for spinal lesions with a prescription of 2,700 cGy to the lesion at
the level of L5 in three fractions.
“While we are seeing other
companies cut back on their
development efforts, Varian
is expanding both the breadth
and depth of our research
collaborations.”
One of the key issues in improving
dose conformity is positioning accuracy. A pelvis phantom study carried out
Current areas of research that are
by researchers at the Duke University
of prime concern to Varian focus on
Medical Center assessed the 3D target
strategies and techniques for improvlocalization accuracy of the cone-beam
ing dose conformity, advances in
CT mode of Varian’s On-Board
image-guided and adaptive radiotherImager® device. Their results showed
apy technologies, and more effective
Michael Sweitzer, Varian Medical Systems
that On-Board Imager’s cone-beam CT
means of motion management. The
imaging is capable of detecting target
AAPM meeting saw many exciting
shifts and patient rotation to within 1 millimeter (mm) and 0.5
new findings and results reported in each of these areas—all
degrees respectively. The shifted target could be realigned to
with connections to Varian. While space constraints prevent
the planned isocenter to within 1-mm accuracy when correctcoverage of all of the research presented at the meeting, this
ing for translational shifts, and within 1.8 mm when correcting
article seeks to highlight just a few interesting, representative
for rotations.
examples.
Improving dose conformity
Improved dose conformity means being able to precisely direct
increasingly higher doses of radiation to increasingly betterdefined targets. Stereotactic radiosurgery (single fraction treatment) and stereotactic radiotherapy (multiple fractions of
treatment) can provide exceptionally good conformity and
have proven particularly valuable for attacking tumors in the
brain and spine. As presentations at the AAPM suggest, the
future for stereotactic treatments looks even better.
CENTERLINE
One of the biggest stirs at this year’s AAPM meeting was
generated by a paper presented by Karl Otto of the British
Columbia Cancer Agency. Otto described a technique called
trajectory-based radiation therapy (TBRT) for planning and
delivering optimized dose distributions with a radiation source
that moves along a continuous three-dimensional trajectory
defined by gantry angle, couch angle, and couch position. Otto
received a prestigious “reviewer’s choice” time slot for a similar
presentation on volumetric arc treatments—a subset of TBRT
—at the ICCR conference in Toronto earlier this year. At
AAPM, he demonstrated that the TBRT technique is well suited for online verification and adaptation, with delivery times
| O C TO B E R 2 0 0 7
13
table, two papers stood out. One came from
Switzerland’s Radiotherapie Hirslanden. A group
of researchers there evaluated the future potential
of applying the On-Board Imager’s
cone-beam CT option to therapy planning that allows dynamic adaptation
for target volume changes. Results with
real patient data demonstrated that a
properly calibrated cone-beam CT
option allows offline treatment planning. Furthermore, the image quality
of the On-Board Imager is sufficient
for contouring target outlines. Conebeam CT, the researchers concluded,
can serve as the control CT in order to
adapt the target volume and resize the
treatment fields and/or optimize the
Dow Wilson, Varian Medical Systems
treatment plan.
that are substantially shorter than static-gantry IMRT,
intensity-modulated arc therapy (IMAT), and
tomotherapy. Says Varian’s Sweitzer, “It appears that
TBRT—and volumetric arc—may
provide better dose conformity than
the treatment modalities in common
use today.”
Adds Dow Wilson, president of
Varian’s Oncology Systems business,
“RapidArc™, which is Varian’s new
technology for single-revolution volumetric arc therapy and a form of
TBRT, will provide better dose conformity than is possible with current
forms of IMRT or tomotherapy.”*
Advancing image-guided and
adaptive radiotherapy
“RapidArc, which is Varian’s
new technology for singlerevolution volumetric arc
therapy and a form of TBRT,
will provide better dose
conformity than is possible
with current forms of IMRT
or tomotherapy.”
While there were scores of Variansupported papers on IGRT imaging and beam-delivery
improvements, there were also significant new developments
reported that pertain to QA processes for IGRT. Two papers in
particular caught Sweitzer’s attention.
The first paper, presented by a team from the Emory
University School of Medicine, described an automated and
comprehensive QA procedure to monitor the coincidence of
mechanical, radiation, and imaging isocenters using conebeam CT and planar X-ray imaging. Performing tests on the
four IGRT-enabled machines available in their institution, the
authors found that coincidence between the mechanical, radiation, and imaging isocenters was within 1 mm for all four
machines, as was isocenter stability with gantry angle. After
image acquisition, the automated software analysis took less
than one minute. They concluded that automated image analysis may be used as a daily QA procedure.
The second paper came from Varian’s own Ginzton
Technology Center. Researchers there have developed an efficient analytical scatter-correction algorithm for the On-Board
Imager. This algorithm can be applied to both the centerdetector and offset-detector geometries used in cone-beam CT.
A scatter-kernel model was implemented in which the cone
beam was modeled as an array of pencil beams. For each of the
pencil beams, a scatter point-spread function was determined
on the basis of measured attenuation values and prior simulations of a polychromatic X-ray beam directed through uniform
material. Based on test results with a pelvis phantom and a
cylindrical water phantom, the researchers demonstrated the
potential for successful implementation of a computationally
efficient scatter-kernel model for the On-Board Imager.
Under the category of adaptive radiotherapy, in which radiation treatment plans are adjusted while a patient is on the
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The second paper was presented
by a collaboration of researchers from the University of
Pittsburgh’s Cancer Institute and the Cancer Institute of New
Jersey, in New Brunswick. They reported the development of a
cone-beam CT–guided online plan modification technique to
compensate for interfractional anatomic changes during IMRT
prostate cancer treatments. Three prostate cases were adapted
to evaluate this proposed online method and the results were
compared with those obtained with bony-structure-based,
prostate-based, and cone-beam CT–based replanning correction strategies. The researchers found that their cone-beam
CT–guided technique is superior to the bony-structure-based
and prostate-based correction techniques, especially when
large interfractional target deformation exists. Its dosimetric
performance is similar to that of the replanning strategy, but
with much higher efficiency.
Motion management
With an increase in treatment volume comes an increased
concern about the issue of motion during treatment delivery.
Scores of papers addressed this concern. One was reported
by a team of researchers from Stanford University. These
researchers examined the problem of intrafraction tumortarget positioning, which they divided into two separate
processes: (1) estimating the real-time target position and
(2) repositioning the beam to account for intrafraction target
motion. In their paper, the Stanford team describes and contrasts various target position estimation and beam repositioning processes that are either available for clinical use or in
development, and they characterize the advantages and disadvantages of these systems.
* Pending FDA 510(k) approval; not available for sale in the United States at this time.
| O C TO B E R 2 0 0 7
Another paper on the topic of motion management was
presented by a collaboration of researchers from Emory and
Georgia Tech, who reported on the 4D dose verification
aspects of treatment plans that involve intrafraction motion. Still
another, presented by a collaboration of Stanford and Varian
researchers, reported on an empirical investigation of 3D
intrafraction motion management using a generalized methodology for tracking, translating, rotating, and deforming targets.
Technology-pushing spirit continues
The papers described here represent only a tiny sample of
those presented at the AAPM meeting that were either directly
supported by Varian or carried out using Varian equipment.
In addition to the research areas already mentioned, there were
also significant developments reported in brachytherapy and
radiobiology (referred to as “biosynergy” at Varian) and even
proton therapy, all of which featured integral contributions
from Varian. The company’s broad and vital presence at the
AAPM meeting was an affirmation that the technology-pushing spirit of the Varian brothers continues to thrive at Varian
Medical Systems. ✺
Join the leader in
cancer-fighting technology.
Lynn Yarris is a freelance science writer.
References
The papers cited in this article were presented at the American Association of Physicists in
Medicine (AAPM) meeting, July 22–26, 2007. Here, in the order of their appearance in the article,
are the titles and authors of those papers. The asterisk (*) indicates the presenting author.
“Intracranial Applications of IMRT-Based Stereotactic Radiosurgery to Treat Multiple or Large
Irregular Lesions,” by J. Wang*, R. Rice, T. Pawlicki, A. Mundt, and K. Murphy, UCSD Medical
Center, La Jolla, California.
“Image-Guided Body Stereotactic Radiotherapy Using Cone-Beam Computer Tomography for
Treatment of Spinal Tumors,” by C. Wang*, A. Shiu, H. Wang, and E. Chang, University of Texas
M.D. Anderson Cancer Center, Houston, Texas.
“A Phantom Study on the 3-D Target Localization Accuracy Using CBCT of an On-Board Imager,”
by L. Zhang*, H. Yan, and F. Yin, Duke University Medical Center, Durham, North Carolina.
“Trajectory-Based Radiation Therapy,” by K. Otto*, British Columbia Cancer Agency,
Vancouver, Canada.
“Automated CBCT QA for Image-Guided Radiation Therapy,” by T. Fox, E. Elder, and
E. Schreibmann*, Emory University School of Medicine, Atlanta, Georgia.
“Scatter Correction for the On-Board Imager Using a Kernel Model,” by J. Star-Lack*, M. Sun,
R. Suri, and G. Virshup, Varian Medical Systems, Mountain View, California, and Baden,
Switzerland.
At Varian Medical Systems, we offer a wide variety
of outstanding career opportunities. And we invite
you to become part of the team working to help clinicians beat cancer by realizing great solutions like
those you read about in Centerline.
You’ll help us create solutions that treat over 100,000
patients a day. And you’ll join a company that was
named #14 in BusinessWeek magazine’s list of Top 50
Performing Companies. We are also a recent winner of
the Computerworld 21st Century Achievement Award,
which recognizes individuals and organizations that use
information technology to benefit society.
“Linac Cone-Beam-CT Option for Treatment Planning: A Possible Approach for Dynamic
Adaptive RadioTherapy,” by P. Cossmann*, A. Stuessi, and C. von Briel, Radiotherapie
Hirslanden, Aarau, Switzerland.
To learn more, visit us at
www.varian.com/careers.
“A Cone Beam CT–guided Online Plan Modification Technique to Correct Interfractional
Anatomic Changes for Prostate Cancer IMRT Treatment,” by W. Fu*, Y. Yang, D. Heron, and
M. Huq, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania, and N. Yue, Cancer
Institute of New Jersey, New Brunswick, New Jersey.
“Intra-Fraction Target-Beam Positioning,” by P. Keall* and A. Sawant, Stanford University,
Stanford, California.
“4D Dose Verification of Treatment Plans Involving Intra-Fraction Motion,” by E. Schreibmann*,
I. Crocker, and T. Fox, Emory University, Atlanta, Georgia, and H. Gozbasi, S. Ahmed, and
M. Savelsbergh, Georgia Tech, Atlanta, Georgia.
“Empirical Investigation of 3D Intrafraction Motion Management Using a Generalized Methodology
for Tracking, Translating, Rotating and Deforming Targets,” by A. Sawant*, P. Keall, V. Srivastava,
R. Venkat, and D. Carlson, Stanford University, Stanford, California, and H. Cattell and
S. Povzner, Varian Medical Systems, Palo Alto, California.
CENTERLINE
| O C TO B E R 2 0 0 7
15
Paperless from the Start:
Two New Comprehensive Cancer
Centers Rely on ARIA
O
n opposite sides of the country, two new
American cancer centers offering medical
and radiation oncology are operating without film or paper. Both designed their processes and
workflow around the ARIA™ oncology information
system from Varian.
Mid Ohio Oncology/Hematology’s
Mark H. Zangmeister Center
Mark Thompson, MD, president of Mid Ohio Oncology/
Hematology (MOOH), had a vision that, over a decade, transformed a small medical oncology practice into a $42 million
cancer treatment center. The Mark H. Zangmeister Center of
Columbus, Ohio, opened in 2007 to provide a full continuum of
oncology care, including medical oncology, radiation oncology,
surgical oncology clinic space, outpatient office visits, diagnostic
imaging, clinical lab services, cancer research and trials, specialty
pharmacy, counseling, and other support and wellness services.
According to Glenn Balasky, executive director of the
Zangmeister Center, MOOH was a group of eight medical
oncologists working in two locations as recently as 1998. “They
had the foresight to adopt the OpTx computerized information
system before almost anyone was thinking about going paperless,” says Balasky. OpTx was later acquired by Varian Medical
Systems and integrated into Varian’s ARIA oncology information system.
“Those doctors saw the future coming and got on board with
automation early,” Balasky says. “In the late 1990s, they were
seeking to create an environment of consistency and scalability
in order to deliver care in exactly the same way across a growing
number of sites. They were also looking at new forms of capitated healthcare, and they knew that they needed better data on
16
CENTERLINE
“An EMR can help prevent mistakes
that happen more easily in a paperbased environment. With consistency
comes improved safety.”
Glenn Balasky, Mark H. Zangmeister Center
what it was costing to deliver care in order to negotiate reasonable contracts.” That meant implementing a comprehensive
electronic medical record (EMR).
There are other benefits to an EMR besides the ability to
aggregate data. “An EMR gives you immediate access to information at any time, whether you’re a medical receptionist
checking someone in or a physician who needs to make clinical
decisions based on lab tests,” Balasky says. “And an EMR can
help prevent mistakes that happen more easily in a paper-based
environment. With consistency comes improved safety.”
MOOH had grown to four offices by 2004, when Balasky was
brought on board to help develop a more integrated care model.
“In this market, people were being sent off for radiation therapy
to the hospitals that offered it, and coordinated care was difficult. Our physicians had to do more work to communicate with
| O C TO B E R 2 0 0 7
a radiation oncologist, and we were sending our patients elsewhere for CT scans, X rays, lab tests, and radiation treatment.
The logistics of delivering care were complicated, not to mention frustrating for patients.”
These considerations led to the development of the
Zangmeister Cancer Center, which opened in May 2007. Twelve
medical and two gynecological oncologists work with a separate
group of radiation oncologists to provide clinical care at the
center. According to Balasky, even though the medical oncology
practice had been utilizing the Varian EMR, it was by no means
a foregone conclusion that they would adopt ARIA for the
entire center. “As much as we valued our relationship with
Varian, we felt we should look at all the options and see everything available from the radiation oncology perspective,” he
says. “After considering our options, however, we decided that
our ultimate goal is what Varian is working toward, namely, a
“Our physicians have never picked up
a paper chart. From day one, even our
billing has been all electronic.”
Tracey Butler, Center for Radiation Therapy of Beverly Hills
completely integrated solution. So we adopted ARIA three
months before the center opened.”
Balasky says the deployment went well, partly because they
started out committed to the paperless environment, allotted
enough time for staff to learn the system, and made sure that
they were using it from day one when they checked in the first
radiotherapy patient for treatment. “We moved into the center
on May 29, but we didn’t schedule radiotherapy patients until
August 15. That gave us plenty of time to learn the system,”
Balasky says. “We were able to start with IMRT planned using
PET/CT images right from day one.”
Balasky points out that cancer patients’ treatment times can
be minimized through efficiency. “When an organization can
manage more services in-house, patients can benefit from
immediate electronic scheduling,” he says. “By consolidating
CENTERLINE
all sides of the house with the ARIA system, we can save time
for the patient by eliminating the need to fill out paperwork in
multiple care settings.”
Reflecting on the rapid evolution of Mid Ohio Oncology/
Hematology and its Zangmeister Center, Balasky says: “Having
an EMR allowed us to build the resources for growing organically and then starting up a brand new center. Right now, for
example, we’re using an outside group to provide our physics
and dosimetry services, and we anticipate outsourcing those
services for at least two years. This allows us to match resource
levels to our current needs. The electronic connectivity possible
with ARIA makes that feasible.”
The Center for Radiation Therapy of Beverly Hills
The Center for Radiation Therapy of Beverly Hills is a newly
established radiation oncology clinic developed by Tower
Hematology Oncology Medical Group and professionally
staffed by Valley Radiotherapy Associates. Open for about one
year, this radiation oncology center saw its first patient in
September 2006 after installing a Clinac® iX with the On-Board
Imager® device. According to Tracey Butler, center manager,
their original plan was to treat 25 to 30 patients per day on a
single linear accelerator. “By the end of the first year, we were
treating close to 49 patients a day, so we decided to add a
Trilogy® machine, which was installed in early March. We started Trilogy treatments in June. Now we’re averaging a little over
60 patients per day.”
Butler was instrumental in helping to establish paperless
processes “from the get-go. The doctors designed the department based on an electronic environment,” she says. “We have
computers in every consultation and exam room as well as at
the nursing station. We can access the medical and radiation
oncology modules on all of our computers, as well as diagnostic
image data from hospitals and freestanding radiology departments in our community. We can also access CT simulation
data stored in the Eclipse™ treatment planning system. Our
physicians have never picked up a paper chart. From day one,
even our billing has been all electronic.”
Leslie E. Botnick, MD, and Christopher M. Rose, MD, the
board-certified radiation oncologists who staff the center, are
committed to a vision of a patient-centric medical record, and
they feel that Varian’s ARIA oncology information system has
taken them a good distance in this direction. “Eventually, what
the cancer survivor community will demand from us is a
portable record that the patient can take from place to place and
that the patient owns,” Rose says. “ARIA’s flexibility makes it
possible for you to create any kind of EMR, whether it’s patient-,
disease-, or treatment-centric.”
All of the center’s clinicians were enthusiastic about working
in a completely paperless environment. “Still, we couldn’t have
accomplished it without an enthusiastic champion in the
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17
department who demanded that we adjust our processes and
learned how to set up dynamic documents within the ARIA system,” Rose says. “Tracey played that role for us.”
“We established a rule,” Butler adds. “If you want something
on paper, fine, but it still has to go into the electronic record.”
That meant that Butler had to become intimately acquainted
with ARIA’s Dynamic Documents feature, which allows her to
create forms that automatically populate certain fields with data
from the EMR. “I learned how to create the electronic documents
that we use throughout our department, following our patientcentric way of working and using information,” she says. “Every
time a therapist comes to me to say, ‘I need a new document for
this or that,’ I’m thrilled. That means they’ve gotten comfortable
with the system. When you keep some piece of information just
in your own mind, if something happens to you, it might take the
department three days to figure out what you were thinking.
Documentation solves those types of problems. Fortunately,
everyone here had the mindset for going paperless.”
Compared with their previous experience using paper charts,
the doctors appreciate accessing every piece of information they
need anywhere within the department. “Thank goodness for
Offline Review,” Butler says. “Most of our treatments use image
guidance, and we have a comprehensive cone-beam CT program, so we’re generating a lot of images. The doctors are comfortable with the system, and they’re reviewing images all day
in real time to satisfy the requirements for IGRT. They also
approve documents throughout the day. We don’t have to chase
Varian Consulting Services:
Help with Clinical Implementations
Many Varian customers have a goal of
migrating their operations to a paperless
environment through use of the ARIA™ system. While some have the luxury of planning
for paperless workflows from the start, most
must transition from current paper-based
practices mixed with some electronic record
keeping. Cathy Tenda, a clinical implementation consultant with Varian’s Customer
Support Services organization, is expert at
helping people analyze their current practices and translate them into electronic
processes that take advantage of ARIA’s many
sophisticated features.
“It takes a lot of collaborative effort, and it
doesn’t happen overnight,” Tenda says.
“When customers are converting to ARIA
from another system, we’re involved up front
for about two months, on average. We look
for potential roadblocks in the customer’s
workflow that may have developed because
their system forces a certain way of doing
things that are done differently with ARIA.
18
them around for signatures or search for them because we need
a document approved. If the system were less user-friendly, this
would all be much harder. We just wouldn’t be able to treat the
number of patients that we do.”
In this paperless environment, the radiation oncology nurse’s
role has evolved. According to Rose, the nurse has become
much more efficient and is able to spend more time with
patients, assessing their responses to therapy and radiation side
effects. “The nurse and the physicians interact with each other
in a more collaborative fashion, using the electronic record as
the collaboration environment,” he says. “Doctors and nurses all
enter patient data into the record. We’ve also been using ARIA
to allow patients to directly enter their own quality-of-life indicators. We even show them tumor response by giving them
direct access to their cone-beam CT images.”
These patient-centered processes are enabling a higher level
of personalized, quality care, according to Rose. “Les Botnick,
Tracey Butler, and I are excited about future enhancements
coming to the ARIA program, tying together staging and treatment information in a tightly linked process of care,” he says.
“In the future, we hope to access the ARIA database, which tells
you everything about every patient and what you’ve done clinically in each case, and link that information up with outcomes,
to really understand what’s working best and for whom. That’s
the future of informatics, and as a paperless center, we’re well
down that road.” ✺
That might require a process change, or it
might require some customization of the
database. Our job is to figure out the shortest distance between the two points and to
help the customer get there with a minimum
of disruption.”
Tenda, herself a radiation therapist and
applications expert, also looks for ways of
reengineering processes for maximum efficiency. “For example, if the departmental secretary is performing a task that it really
makes sense for the nurse to do, we can help
structure a change that takes advantage of
the ARIA system’s greatest strengths.”
Sue Merritt, Varian’s manager of clinical
implementation consulting, explains that
consulting services start with a detailed
analysis of “what is,” to fully understand how
the customer is currently working. The consultant then helps to configure ARIA to support their processes.
“We gather every piece of paper a customer
uses, whether it’s a form the patient receives
or a document the clinician needs,” Tenda
says. “We analyze them to determine if the
function can be eliminated, if it’s something
CENTERLINE
| O C TO B E R 2 0 0 7
that’s already part of ARIA, or if it can be
added to the system using Dynamic
Documents. We talk about it with the customer as we develop the “to be” workflow
map. Because we know the ARIA system, we
know where each element fits in and we can
come close to mimicking what the customer
is currently doing.”
Tenda also sometimes weaves in some “best
practices” suggestions based on her experience with optimal ways of using ARIA. “But
the main goal is to get the customer up and
running as quickly as possible without a lot
of changes to their processes,” she says.
According to Merritt, Varian is planning to
launch comprehensive “best practices” consulting services in 2008 to augment the services already offered for those converting to
ARIA. “This is for customers who have been
working with ARIA for some time and are
looking to maximize their efficiency through
more rigorous process reengineering. By the
year 2010, the U.S. government is going to
require all cancer centers to be operating
electronically. Varian is dedicated to helping
customers get there.” ✺
FOCUS ON SERVICE | SECOND IN A SERIES
Medical physicist Byong Yi, PhD, conducts quality assurance tests
on a newly installed Trilogy linear accelerator at the University of
Maryland School of Medicine.
Installation Times for IGRT Upgrades
and New Machines Cut in Half
By Steven K. Wagner
V
arian’s Customer Support Services organization is a far-reaching network of professionals dedicated to meeting customers’ needs for
service and support. Approximately 1,500 people work
in positions that directly support customers, whether by
staffing the help desk, managing system installations,
providing implementation instruction, or dispatching
field engineers. “We aim to provide unsurpassed support
so our customers’ clinical teams can focus on patient
care,” says Kolleen Kennedy, Varian’s vice president of
worldwide customer support.
With this issue, Centerline publishes its second installment on service and support, focusing on the teams that
handle new installations as well as major upgrades.
CENTERLINE
As they pondered adding sophisticated new technology from
Varian Medical Systems, the principals at NY Radiation
Associates didn’t want to underestimate the time it would take
to add an On-Board Imager® device to their existing linear
accelerator. Timing, they reasoned, would be crucial to the success of any effort that enabled implementation of image-guided
radiation therapy (IGRT). It was then mid-2006.
Fortunately for Jack Dalton, MD, and his partner, Roberto
Lipsztein, MD, just as they were considering how their practice
might fare during the downtime, Varian made an exciting
announcement: every effort would now be made to install OnBoard Imager devices within 5 to 10 business days, and IGRTenabled Clinac® systems within about a month—cutting installation times in half.
| O C TO B E R 2 0 0 7
19
of radiation oncology. “There was always
someone here to keep the process moving—seven days a week,” adds physicist
Anthony Z. Cole. “It went very, very well.”
“We were originally looking at upgrading over several weeks, which wouldn’t
have been optimal but we probably could
have lived with it,” says Dalton, whose
clinic is situated in Queens, New York.
“When Varian committed to a reduced
schedule, it provided us with a huge
opportunity to reduce the amount of
downtime we needed to anticipate.”
With the expedited installation process
now taking hold in North America,
Varian’s presence has been enhanced on a
broad scale—from Europe to North
America. Just ask Mary Houston, principal
physicist at Mater Private Hospital in
Dublin, Ireland. The hospital’s installation
was completed on February 13, 2007.
Preparing for success
Both an On-Board Imager upgrade and
a complete IGRT installation require that
specific preparatory tasks be completed
at the customer site prior to commencement of the installation. Varian project
managers work closely with customers to
ensure that all necessary preparations take
place so that installations can proceed
successfully within the accelerated time
frame.
“They changed their schedules
to suit our needs. By working
through the weekends, they
completed the installation
ahead of schedule.
We’re very happy.”
Mary Houston, Mater Private Hospital
To shorten the time required for
these installations, Varian undertook a
systematic study of the company’s operations around the world, focusing on best practices that resulted
in the fastest, smoothest installations. These successful labor
processes were analyzed and broken down to identify ways to
save time by managing in parallel what had previously been
serial tasks. The new processes were then formalized and adopted on a worldwide basis.
Steven K. Wagner is a freelance journalist who
specializes in healthcare and medical topics.
Milestones for a five-week complete installation
According to Dalton, the entire installation process went as
smoothly as possible—something he attributes to the remarkable
teamwork and cooperative spirit exhibited by his staff and
Varian. “Collaboration was the key,” he says. “Having everything
completed at our end by the time Varian arrived for the installation, and also having all the parts on hand, was essential. In the
end, the installation was finished a week early. I was absolutely
thrilled and delighted.”
“Varian prepared us extremely well for the upgrade, and
things went perfectly,” Dalton adds. “Not kind of perfectly, not
sort of perfectly. They went absolutely perfectly.”
• Powering up of the accelerator, multileaf collimator, and
On-Board Imager device.
• Beam output and functional testing of the accelerator.
• Alignment and operational testing of the accelerator.
• Alignment and operational testing of the On-Board
Imager device.
• Alignment and operational testing of the PortalVision™
unit.
Milestones for an upgrade of 5 to 10 clinical days*
Staff members at Wellmont Holston Valley Medical Center, in
Kingsport, Tennessee, where Varian installed a Clinac iX with
the On-Board Imager, tell of a similar success. Site preparation
for their installation began on October 9, 2006, and Varian engineers completed the full installation on November 13.
“Varian was absolutely wonderful. They kept us on track, kept
us informed, and really kept things moving. The entire process
went very smoothly,” says Catherine M. Gott, clinical manager
CENTERLINE
• Rigging of the linear accelerator and On-Board
Imager device.
• Customer approval.
On schedule—or ahead
20
“The installation staff was efficient and
organized, and they understood the pressures of running a department on a single
accelerator while the replacement was
ongoing,” Houston says. “They changed
their schedules to suit our needs. By working through the weekends, they completed
the installation ahead of schedule. We’re
very happy.” ✺
• Completion of the major mechanical installation: mounting
of the On-Board Imager arms, completion of the console
assembly, and interconnection of all cables.
• Completion of the configuration, alignments, and imaging
system calibration.
• Customer acceptance testing for the On-Board Imager,
PortalVision, and other specifications.
• Beginning of customer training and observation of
treatment resumption.
* The process can take place in a week if two full weekends are included.
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T R A I N I N G U P D AT E S
Visit http://www.varian.com/oncy/new117.html for a complete calendar of conferences and events.
North American training opportunities
High-Dose-Rate Brachytherapy
for Prostate, Gynecological,
and Breast Cancer course
IGRT Short Course
Stanford University Cancer Center
Stanford, California
Ultrasound-Guided Transperineal
Brachytherapy for Early-Stage Prostate
Cancer course
Seattle Prostate Institute
Seattle, Washington
January 18–19, 2008
May 2–3, 2008
Seattle Prostate Institute
Seattle, Washington
November 12–13, 2007
February 25–26, 2008
June 23–24, 2008
Visit: http://www.stanford.edu/~lei
December 10–11, 2007
January 14–15, 2008
March 3–4, 2008
June 9–10, 2008
IMRT School
Visit: http://www.seattleprostateinst
.com/coursedescriptions.htm
UMass Memorial Medical Center
Worcester, Massachusetts
IGRT School for Radiation Therapists
MIMA Cancer Center
Melbourne, Florida
Visit: http://www.seattleprostateinst
.com/coursedescriptions.htm
March 29–30, 2008
Visit: http://www.knownexus.com/
Varian product training programs
Varian Training Centers
Ongoing; three-day sessions
frequently scheduled
Milpitas, California, and Las Vegas, Nevada
Visit: http://www.varian.com/courses
Call: 321.409.1956
European training opportunities
Call +41 (0) 41.749.88.44 or e-mail [email protected] to learn more about European training opportunities.
Acuity™ Support course
Crawley, UK
January 21–25, 2008
April 14–18, 2008
June 30–July 4, 2008
Acuity Technical
Maintenance course
Crawley, UK
November 5–9, 2007
January 28–February 1, 2008
April 21–25, 2008
Eclipse™ Application course
Zug, Switzerland
November 13–15, 2007
December 11–13, 2007
January 15–17, 2008
February 19–21, 2008
March 11–13, 2008
April 15–17, 2008
May 27–29, 2008
Eclipse in Clinical Practice
course
Zug, Switzerland
January 18, 2008
Gating School
February 22, 2008
March 14, 2008
April 18, 2008
May 30, 2008
Copenhagen, Denmark
November 15–17, 2007
Eclipse Management
course
IGRT School
Wirral, UK
December 6–8, 2007
Zug, Switzerland
November 6–9, 2007
December 4–7, 2007
January 8–11, 2008
February 12–15, 2008
March 4–7, 2008
April 8–11, 2008
May 20–23, 2008
June 24–27, 2008
IMRT School
Berlin, Germany
November 27–30, 2007
January 22–25, 2008
March 11–14, 2008
May 20–23, 2008
Dijon, France
Electron Monte Carlo
Algorithm course
February 26–29, 2008
Zug, Switzerland
Oncology Information
System Administration
course
November 9, 2007
December 7, 2007
January 11, 2008
February 15, 2008
March 7, 2008
April 11, 2008
May 23, 2008
June 27, 2008
May 5–9, 2008
June 9–13, 2008
Oncology Information
System Implementation
course
Zug, Switzerland
November 6–9, 2007
December 4–7, 2007
January 15–18, 2008
February 12–15, 2008
March 11–14, 2008
April 15–18, 2008
May 27–30, 2008
June 24–27, 2008
Oncology Information
System Reports course
Zug, Switzerland
November 20–22, 2007
February 26–28, 2008
April 22–24, 2008
Zug, Switzerland
November 12–16, 2007
December 10–14, 2007
February 4–8, 2008
March 3–7, 2008
April 7–11, 2008
CENTERLINE
| O C TO B E R 2 0 0 7
21
When battling cancer,
every second counts.
Put time on your side.
RapidArc .
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