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    Hello, everybody. I'm really thanks to be here, the possibility that Brainlab give me to me. Well, I am radiation oncologist. I will present our experience in the use of Brainlab Elements we use for spine before Iplan, we migrated. So I will show part of the history and how we use, which I consider the benefits from this tool. As you can see, we dedicate a lot of our practice to the SBRT and SRS.

    So, this is not the important part of my talk. But, of course, we use SBRT for all these indications that are already validated and were presented before. We use the selection criteria international validated in our institutional protocol. And for the cases that you will see, we have had a very exhaustive selection criteria. And we defined, at the moment that we start with SBRT process in 2012, with an institutional protocol based on the international published information.

    So, as you can see here, we started in 2012 with Iplan up to 2017. We do almost 300 patients from SBRT spine. Our experience was really...well, we were mostly of the patient with three fractions, as you can see, 9 gray, but related to some persistent illness or local recurrence, we migrate after to the scale of 3 times 12. At the moment, if well, I won't present information for clinical results, we didn't see a difference in risk of local fracture that was very important for us.

    Some cases that we treat, for example, this case, this woman with sacral chordoma. And this was a very special schedule. And as you can see, the whole volume that we should treat, it was very important case. We were very worried about the results because the volume was really high. But this was the start, as you can see, with Iplan. And our results really were very satisfactory. So that was one of the cases that gave us the opportunity to start to take results and to see the toxicity and the control of the illness.

    This other case for cervical chordoma too, very, very difficult cases to define the volume. And we know that in some of these cases, we were sometimes outside the international protocols, but we have to give a solution to the patient. And we work a lot with not only the local consult too with the organelles. So for this case, we had very good local control, the tolerance was really good. So with all these cases that we work and this one more from spine soft tissues lesion, I think that there were a lot of experience that we accumulate and a lot of evaluation from the results.

    But the point is that at the moment, that we have the new possibility or the possibility to migrate to Elements was to analyze why should we change a system that at the moment works really well with our bodies? And one of the reasons was the facility to work with the system, not directly basically that this one with the results because we didn't test it, but we look for the facility in the workflow. And that is a very important point. So in this case, I will show the case and we will analyze a little bit more of that. This is a spine metastasis. We identify here very well the blastic area, and then all the CTV.

    At this moment, we asked Brainlab with one...I can say we have a very good customer relation, and that we need to focalize the GTV, individualize from the CTV. So we wanted to give a higher dose here when we saw the lesion, and we wanted to give a lesser dose outside where we know that the guidelines say that we should irradiate, but we didn't see anything wrong or blastic area. And the problem is that if we give 36 gray to the whole CTV, the dose to the spine would be difficult to reach the constraint.

    So we treat this patient, as you can see here, GTV 36, CTV 27. The position is everything described is very standard for SBRT treatment. Of course, we define the volume, they make a lot of define the volume, and data is already with the Elements system. And that is a very, very important tool that when you define the GTV, the system define automatically the CTV. And I will come back in the next slide to this point, because this is a very, very important point to the uniformity [inaudible 00:06:37] to work.

    So, at this point, we have here the differential dose., as you can see 27 and here 36. And we take care and we respect the dose contracts to the spine, without to reduce in a significant way the dose to the area where is the GTV. And that is very important because before that, we have the 36 area in the whole CTV, and we have big reductions of the dose where in DCTV that didn't make sense to give. So, just high dose everywhere.

    We take the experience, for example, of course, as you have seen before in the talk from Dr. Papanikolaou, the work with the planification, everything has been well described, the QA we do too with Delta4. So the whole process is done very well before the patient arrive to the treatment machine. And we control the treatment every fraction into a fraction before and during the SBRT with the ExacTrac. We take care a lot from the movement and the tolerance from the patient.

    So, how is the daily work with this system? The first point is, as I told you, this is my area. I mean, I will control, find the volume, I will control, they automatically control and I will control after that the [inaudible 00:08:28] doses. So, the slide, the total perpendicular show you have all the buttons to go where you want to work. And when you have the image fusion, that is a very important point because this elastic fusion that makes consideration very important, the most important is that you will be sure that the spine is where it should be in the fusion because you will control the spine by the MRI. So if the fusion is not perfect, we are going to miss the point or maybe to have a risk, this organelle risk.

    After that we choose the spine button, so we choose the image that we will use. And we go to this first area where we have this completely different visualization of all the image and the volume that we will use. As you can see here is the CT scan and here is the MRI scan. It should be done in a very precise protocol. And what is important here is we can use many different ways to work or to see the information, but at least we have a very complete visualization of the area that you will work or define.

    The system make an automatically controlling of all the vertebrates, and we identify every one of them. So that is very, very important too, sometime is more useful, sometime is not so, but it's a nice tool. And at this moment, we start to control or to define the GTV area that you can see here very well in MRI, but you can see here very well in the CT scan too. At the moment, you define this volume and you will put the name that it is a GTV. We can use to the [inaudible 00:10:45] information. And that is put... I put here something is nothing to do with the Elements, it was a word that we do about breast cancer contouring.

    What we are using or when we are using the Elements, we diminish the variability interobserver that have already been published for all the pathology. And when you have a guideline, you diminish, choose this interobserver variability. But it doesn't mean that every interobserver or person that will contour will respect that. So, to avoid that, I think that this system from Brainlab is really very useful, because it will contour automatically the CTV related to the GTV in relation to the guidelines. So the interobserver ability disappear, and this is very, very important.

    Then we will see the dose planning, we go to take off in the physical department we work. And we can see the dose distribution related to the differentiate dose too. We can see here a very nice visualization with higher dose in the 36 gray area, and the lower dose in the 27 gray area and with a very good protection of the spine. So, one thing that is very good too is the way to see all the image together, and to see the conformal index, and to see the percentage of volume treated and the image at the same time that is very useful and very practical that you don't need to go from one screen to the other. Simple things, but that will increase or perform the workflow that will be...it will be better.

    So, in conclusion, what is gives Elements to us in difference to the Iplan, the MRI curvature correction, the automatic segmentation of the OARs and vertebrae, and that is related with the GTV delineation and the CTV automatic delineation should reduce the interobserver variability. Automatic planning because it's not only for the medical doctor, the benefit. The physics department, they will put a template and the system will work in a more homogeneous way independent from the physic or the person. And that is a very important point when you work in a group of people that is not only one, the one that we contour that will planify. It is is a very important point that was very important for us. So don't need future planning structures, less treatment time, and better CI and GI so the conformal index is better. So that's all. Thank you.
    Info
    Title:
    Clinical Experience Utilizing Elements Spine SRS
    Topic:
    Spine radiosurgery
    Year:
    2019
    Speaker:
    Peña Pablo Castro
    Language:
    English
    Category:
    Interests:
    Duration:
    14:23
    Date:

    Pablo Castro Peña, MD, Radiation Oncologist at Instituto Zunino – Fundacion Marie Curie in Cordoba, Argentina, reveals his institution’s first clinical experiences with Elements Spine SRS software. He begins by outlining the types of spine indications they treat before delving directly into an analysis of specific case examples. In terms of these cases, he discusses a range of functionalities of Spine SRS including curvature correction, automatic segmentation of OARS and vertebrae, GTV delineation and automatic CTV creation as well as automatic protocol-based planning.

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