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IMRT/IGRT Patient Treatment: A Community Hospital Experience


Treatment Planning System QA in Era of IGRT

Image Guided Radiation Therapy (IGRT) Program Implementation: A How To Guide
By Charles M. Able, MS

Development of any clinical program is a team effort.  If you have been given the sole responsibility for program development then this may be an opportunity to change the process at your facility. I suggest you read AAPM Task Group 40 and ACR Practice Guidelines Radiation Oncology.  These documents clearly define the organizational structure of a continuous quality improvement program which is tasked with oversite of clinical program implementation and maintenance.  This guide will assume IGRT will include the use of diagnostic x-ray imaging capability (2D and CBCT) in the treatment room.

The first step is to form an IGRT Team/Committee which consist of a medical physicist, radiation oncologist, dosimetrist, therapist, and an administrator.

The committee will perform an exhaustive literature review to find answers to the following questions:

• Which body sites will benefit most from IGRT?
• What process has shown best results: implantable markers, 2D imaging, CBCT?
• Is there special or increased immobilization needed?
• What about inter vs intra fraction motion and repeat imaging?
• Will we need special quality assurance of equipment and/or treatment delivery?

Once the review is complete and discussed a clearer picture of how your program will be structured emerges.

Each area then needs to work on specific assignments with time lines/deadlines stipulated:

• Physics: test the imaging system and setup any imaging protocols required and walk through the process with the vendor representative to gain a full understanding of the limitations and capabilities of the system.  Refine the process steps from a systems level point of view.
• Physicians need to consider how they will localize the patient position: will they use bony anatomy, markers, contoured soft tissue structures; which techniques for which body sites?
• Physicians need to understand that their leadership is critical during the startup phase.  The clinic schedule must be adjusted to ensure they can efficiently review images at the console to ensure integrity of the process.  This is vital to the success of the program.
• Therapist: schedule time to work through the imaging process with a dummy patient plan and phantom. This will help to understand the steps and flow of the process without the pressure of a live treatment.
• Simulation Therapist:  Determine the immobilization options available.  Purchase and learn how to make, fit, and/or shape the immobilization by practicing on a fellow staff  member.
• Administrator: Determine what the billing requirements are - medical necessity, proper documentation of physicians order and procedure implementation and completion, specific codes appropriate to your facility.

Once these assignments have been completed and the results shared with the IGRT team, decide on one particular body site to start the program.  If your radiation oncologist are like ours they will want to just open the program up to anyone that clinically needs more precise positioning.  I advise against this because image localization at treatment delivery is a paradigm shift.  The therapist may not be comfortable using image localization.  They need to learn the mental process of the physicians involved for a particular body site and then build their confidence and knowledge about what is acceptable to the physician and what is not.

The medical physicist is responsible for establishing the quality assurance program for the imaging and positioning system.  This must include daily verification of the accuracy of the patient reposition system/subsystem of the IGRT system software.  This will add time to the daily warm-up but can be performed by the therapist.

You  are now ready to launch your IGRT program clinically.  The IGRT team/committee should continue to meet on a monthly then quarterly basis to continue to adjust procedures and refine the process.

Please use the "IMRT/IGRT Patient Treatment: A Community Hospital Experience" link to review the experience at a typical community hospital radiation oncology department.