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1. Intro_DBN16.pdf
1

Welcome toAdvanced Skills for Modern Radiation Therapy- RTT only -
1

Slide Number 2
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Slide Number 19
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Slide Number 20
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Slide Number 21
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3. Patient preparation and positioning_MKA
22

Slide Number 1
22

Patient Preparation and Positioning
23

Slide Number 3
24

Slide Number 4
25

Expectation management
26

Slide Number 6
27

Slide Number 7
28

Slide Number 8
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Pelvic patients: dietary protocol
30

Slide Number 10
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Prostate patients
32

Slide Number 12
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Slide Number 13
34

Slide Number 14
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Slide Number 15
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Slide Number 16
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Slide Number 17
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Creating unfortunate differences
39

Example 1: Look for differences..
40

Slide Number 20
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Slide Number 21
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Slide Number 22
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Slide Number 25
44

Practical session
45

Slide Number 27
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Slide Number 28
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Slide Number 29
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Slide Number 30
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Slide Number 31
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Slide Number 32
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Slide Number 33
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Rectum patients
53

Slide Number 35
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Essential: education & compliance
55

Slide Number 37
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Slide Number 38
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Slide Number 39
58

4. Josipovic Pre-treatment imaging
59

5. Delineation_SR
119

Slide Number 1
119

Which are the 3 weakest points in our modern radiotherapy treatment chain?
120

Learning outcomes
121

Delineation: one of the links in the treatment chain
122

Why is delineation important?
123

Do we need to improve?
124

How can we answer that need ?
125

Did you know before this course that ESTRO provides a platform for hands on exercises on contouring?
126

Inter-observer variability in contouring
127

Does heterogeneity in RT matters?
128

Hypoxia radioresistance
129

Slide Number 12
130

Slide Number 13
131

Slide Number 14
132

How to improve?
133

ICRU Guidelines (ICRU50): volume definition
134

Tumor Gross Volume: GTV
135

Tumor Gross Volume: GTV
136

Tumor Gross Volume: GTV
137

PET scans in delineation of lung cancer
138

Tumor Gross Volume: GTV
139

Clinical Target Volume: CTV
140

CTV
141

Clinical Target Volume: CTV
142

GTV and CTV
143

Planning Target Volume: PTV
144

PTV
145

Irradiated Volume and Treated Volume: IRV and TV
146

ICRU 50
147

ICRU 62 (in addition to ICRU 50)
148

Set up Margin: SM
149

What is the definition of the ITV?
150

What is the definition of the PTV?
151

Slide Number 34
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Slide Number 35
153

Contouring Guidelines
154

Contouring Guidelines
155

Contouring Guidelines
156

Contouring guidelines
157

Contouring guidelines
158

ESTRO guidelines
159

Take home messages:- Inter observer variability in contouring can translate in a systematic error- Need for a common language: ICRU - Need for delineation guidelines- Need for teaching in contouring
160

Thank you for you attention
161

Which are the 3 weakest points in our modern radiotherapy treatment chain?
162

6. Forde_OAR Delineation 2016
163

11. Josipovic Image registration
220

14. Josipovic Motion management
261

15. Forde_Planning 2016
301

16. In-room imaging modalities_MK def 2003
356

Slide Number 1
356

Content of the presentation
357

At the start of treatment
358

In fact…it’s just a snapshot
359

Why do we need imaging on the linac?
360

Imaging modalities
361

Ultrasound systems
362

More recent developments
363

Ultrasound system
364

Electromagnetic tracking
365

Electromagnetic tracking
366

Electromagnetic tracking (GPS)
367

Portal Imaging - physics
368

Goals of PortaI Imaging
369

Technical aspects of EPIDs
370

Examples of portal images (open field)
371

EPID – field images
372

Electronic Portal Imaging
373

2D kV imaging
374

kV source moutend on linac
375

kV imaging: Cyberknife
376

Slide Number 22
377

Exac Trac® IGRT system
378

OBI kV imaging
379

kV imaging
380

Cone beam CT
381

CBCT Acquisition
382

How does it work?
383

Image registration: Defining the ROI
384

Image registration: Defining the ROI
385

Image registration
386

Image registration: bony anatomy
387

Image registration: fiducial markers
388

CBCT imaging
389

MV-(CB)CT
390

MV-CT
391

Videosystems
392

Exac trac infrared
393

Surface scanning
394

Infra red systems
395

Slide Number 41
396

Integrating MRI functionality with external beam radiotherapy
397

Gantry design MRL: (MRI-Linac)
398

MRIdian: MR Cobalt
399

MR linac
400

How accurate should the delivery be?
401

17. Clinical rationale for IGRT_Jose Lopez_clean
402

Slide Number 1
402

Learning Objectives (IGRT)
403

Wikipedia
404

Why do we need IGRT?
405

Slide Number 5
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Slide Number 6
407

Slide Number 7
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Slide Number 8
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Slide Number 9
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Slide Number 10
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Slide Number 11
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Rationale for IGRT
413

Slide Number 13
414

Imaging for treatment verification
415

Technologies available for IGRT
416

Technologies available for IGRT
417

Slide Number 17
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Slide Number 18
419

Slide Number 19
420

Rationale for IGRT
421

Slide Number 21
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Slide Number 22
423

IGRT
424

Slide Number 24
425

Slide Number 25
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Slide Number 26
427

Sources for Clinical Rationale
428

Cites in Pubmed (2014-2016)
429

Clinical trial, Phase III(compare new treatments with the standard)
430

Clinical trial, Phase III
431

COST and TIME
432

Clinical trial, Phase II (N = 74)(if a new treatment works well)
433

Toxicity
434

Phase II (Prostate)
435

Slide Number 35
436

Slide Number 36
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Slide Number 37
438

Prostate IGRT
439

Prostate IGRT
440

Clinical trial, Phase II (hepatocellular carcinoma )
441

Clinical trial, Phase II (Sarcoma)
442

Clinical trial, Phase II (Lung)
443

Clinical trial, Phase II (oligometastases)
444

Clinical trial, Phase II (head and neck)
445

Slide Number 45
446

Adaptive radiotherapy
447

FUTURE DIRECTIONS (phase III studies on-going)
448

FUTURE DIRECTIONS
449

IGRT confidence and knowledge
450

IGRT confidence and knowledge
451

CONCLUSIONS: Why IGRT?
452

Slide Number 52
453

19. Prostate_Jose Lopez
454

Slide Number 1
454

Outline of Talk
455

Slide Number 3
456

Lymph nodemetastasized prostate cancer
457

Lymph nodemetastasized prostate cancer
458

Lymph nodemetastasized prostate cancer
459

Lymph nodemetastasized prostate cancer
460

Lymph nodemetastasized prostate cancer
461

Lymph nodemetastasized prostate cancer
462

Slide Number 10
463

Slide Number 11
464

Slide Number 12
465

Slide Number 13
466

Slide Number 14
467

Case 1: patient with stage N+ (D1) disease
468

Case 1: patient with stage N+ (D1) disease
469

Case 1: patient with stage N+ (D1) disease
470

Slide Number 18
471

Slide Number 19
472

Prostate
473

Slide Number 21
474

Slide Number 22
475

PTV (prostate gland+5mm margin)
476

Seminal vesicles planning volume (orange)
477

Pelvic lymph nodes planning volume(prophylactic [purple], positive [red])
478

Slide Number 26
479

Slide Number 27
480

20. Josipovic Prostate physicists perspective
481

21. Prostate_MK
500

IGRT for prostate cancer: RTT perspective
500

Content
501

Offline/Online bony anatomy matching
502

Offline/Online bony anatomy matching
503

Offline marker registration using fiducial markers
504

Problem/challenge
505

Fiducial markers
506

Fiducial markers: offline
507

Fiducial markers: offline
508

Online fiducial marker registration
509

Food for thought!
510

Food for thought!
511

Online Position Verification
512

Offline vs Online
513

Online Position Verification
514

Online marker registration using CBCT
515

ConeBeam CT: soft tissue information
516

Many ways to Rome!
517

The N1 case
518

Option 1: solved by margins (AMC)
519

Option 2: Adaptive procedure
520

Bladder: Focal adaptive margin strategy
521

Thank you for your attention!
522

22. 2016_Cervix_SR
523

Slide Number 1
523

Cervix cancer diagnosis OMS (2002)
524

Patient History
525

Slide Number 5
526

Slide Number 6
527

Slide Number 7
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Slide Number 8
529

Slide Number 9
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Slide Number 10
531

Slide Number 11
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Slide Number 12
533

Slide Number 13
534

Heterogeneity in contouring target volumes besides the use of guidelines
535

Quite good homogeneity in some OAR contouring
536

But it’s not always the case!
537

Upper and lower limits are a source of heterogeneity in contouring as well
538

Take home messages:- High quality CT, MR imaging and clinical examination are crucial for contouring targets and OAR in the pelvic region- High quality re-imaging and clinical examination are key points in cervical cancer to adapt contours for brachytherapy dosimetry- MR is a key imaging modality in gynecology
539

24. Cervix_DBN16_RdJ
540

Slide Number 1
540

CervixART Planselection
541

Slide Number 3
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Slide Number 4
543

Slide Number 5
544

Slide Number 6
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Slide Number 7
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Slide Number 8
547

Slide Number 9
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Slide Number 10
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Slide Number 11
550

Slide Number 12
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Slide Number 13
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Slide Number 14
553

Question
554

Observer study setup
555

Patient 1
556

Patient 2
557

Slide Number 19
558

Result
559

Slide Number 21
560

Slide Number 22
561

Slide Number 23
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Slide Number 24
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Slide Number 25
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Slide Number 26
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Slide Number 27
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Slide Number 28
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Slide Number 29
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Slide Number 30
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Slide Number 31
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Slide Number 32
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Slide Number 33
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Slide Number 34
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Slide Number 35
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Slide Number 36
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Slide Number 37
576

Slide Number 38
577

25. Lung_Jose Lopez
578

Slide Number 1
578

Slide Number 2
579

Outline of Talk
580

Introduction
581

Introduction
582

Slide Number 6
583

Slide Number 7
584

Recent Trials Addressing Management of Oligometastatic NSCLC
585

Slide Number 9
586

STEREOTACTIC ABLATIVE RADIOTHERAPY DELIVERED BY HELICAL TOMOTHERAPY FOR EXTRACRANEAL OLIGOMETASTASIS
587

STEREOTACTIC ABLATIVE RADIOTHERAPY DELIVERED BY HELICAL TOMOTHERAPY FOR EXTRACRANEAL OLIGOMETASTASIS
588

Slide Number 12
589

Slide Number 13
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Slide Number 14
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Slide Number 15
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Slide Number 16
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Slide Number 17
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Slide Number 18
595

Case 1: Oligorecurrence of lung cancer
596

Slide Number 20
597

Slide Number 21
598

Slide Number 22
599

Motion artifacts are commonly seen with thoracic CT images
600

Motion artifacts
601

Tumor movement
602

Slide Number 26
603

Slide Number 27
604

Slide Number 28
605

26. Josipovic Lung physicists perspective
606

27. Lung_MK
626

Lung SBRT on the linac
626

Key features SBRT
627

What do we have to manage?
628

Intra fraction motion: amplitude
629

Inter fraction motion: baseline shift
630

Baseline shift
631

Slide Number 7
632

Slide Number 8
633

Managing intra fraction motion
634

Management of baseline shifts
635

Option 1: NKI/ELEKTA solution
636

Option 1: NKI/ELEKTA solution
637

Option 2: critical isodose
638

Option 3: homemade excel sheet
639

Reference CT: OAR ROI (Clipbox)
640

Reference CT: Tumor ROI (Mask)
641

Step 1: image registration on OAR
642

Step 2: image registration on tumor
643

Verify the registration
644

Slide Number 20
645

Convert to correction
646

Registration data in overview tab
647

Fill in data in excel sheet
648

Perform table correction and 2nd CBCT
649

Fill in data of 2nd CBCT in excel sheet
650

Starting treatment?
651

Slide Number 27
652

Thank you for your attention!
653

28. Breast_2SR_clean
654

Slide Number 1
654

Clinical case
655

Mammograms + US
656

Angio mammography
657

Breast MRI
658

Clinical case
659

Therapeutic strategy: Which radiotherapy?
660

Slide Number 8
661

Slide Number 9
662

Partial breast irradiation indication guidelines
663

Intraoperative Partial breast versus whole breast irradiation
664

Slide Number 12
665

EBRT allows for conformal treatment
666

Slide Number 14
667

PAPBI: first résults
668

Dosimetry
669

Dosimetry
670

Dosimetric comparision between APBI
671

Re-positionning control
672

Heart Toxicity
673

Cardiac risk is increased by cardiovascular risk factors
674

Improved heart sparing by breath hold
675

How to improve heart sparing?
676

Take home messages:- Accelerated hypofractionated whole breast and partial breast irradiation are changing our practices for early breast cancers with good prognosis factors- Contouring and positioning remain key points for these treatment strategies- Moving toward better sparing OAR means we need to assess low dose consequences as well
677

30. Breast RTT Perspective 2016
678

32. Forde_Varian CBCT 2016
705

33. WorkshopImageRegistrationElekta_DBN16
771

‘steps’of registration @AMC
771

Reference settings – 1x
772

Image registration and evaluation
773

Image registration and evaluation
774

Image registration and evaluation
775

Symantics @Elekta
776

Slide Number 7
777

Slide Number 8
778

Slide Number 9
779

Algorithms @Elekta
780

Algorithms
781

Slide Number 12
782

Slide Number 13
783

Bone and seed algoritme
784

Bone and seed algoritme
785

Algoritmes
786

Cons:Local minima: specifically a problem for small regions of interest depending on cost function
787

Slide Number 18
788

Slide Number 19
789

CRP @Elekta
790

Correction Reference Point
791

Correction Reference Point
792

Correction Reference Point
793

Correction Reference Point
794

Correction Reference Point
795

Slide Number 26
796

Slide Number 27
797

Slide Number 28
798

34. Head&neck_SR
799

Slide Number 1
799

Changing traditional scenario in H&N cancer
800

Patient history
801

Clinical examination
802

Slide Number 5
803

Slide Number 6
804

Slide Number 7
805

Slide Number 8
806

Slide Number 9
807

Slide Number 10
808

Slide Number 11
809

Slide Number 12
810

Slide Number 13
811

Slide Number 14
812

Slide Number 15
813

Slide Number 16
814

Slide Number 17
815

Slide Number 18
816

Slide Number 19
817

Slide Number 20
818

Slide Number 21
819

Slide Number 22
820

Contouring guidelines
821

Case used for H&N Falcon online WS
822

Take home messages:- HPV positive tumors are changing H&N cancer traditional scenario- Positioning remain key points for these highly conformal treatments (IMRT+++)- Target and OAR contouring remains an issue: Highly heterogeneous contours- Crucial need for contouring guidelines and training
823

36. Forde_H and N RTT Perspective 2016
824

37. Brain_Jose Lopez
844

Slide Number 1
844

Outline of Talk
845

Pearls
846

Inmovilization
847

Planning images
848

Slide Number 6
849

Slide Number 7
850

Slide Number 8
851

Slide Number 9
852

Slide Number 10
853

Technologies
854

Slide Number 12
855

Slide Number 13
856

Slide Number 14
857

Slide Number 15
858

Slide Number 16
859

Slide Number 17
860

Slide Number 18
861

BRAGG PEAK
862

Slide Number 20
863

Slide Number 21
864

PTC
865

Slide Number 23
866

Case 1: patient with teratoid rhabdoid tumor
867

Slide Number 25
868

Mass at the fourth ventricle
869

Slide Number 27
870

Slide Number 28
871

Slide Number 29
872

PTV (surgical bed + 5 mm margin)
873

PTV
874

Slide Number 32
875

Slide Number 33
876

38. Josipovic Brain physicists perspective
877

39. Brain_DBN16_RdJ
898

Slide Number 1
898

Brain
899

Slide Number 3
900

Slide Number 4
901

Slide Number 5
902

Slide Number 6
903

Slide Number 7
904

Slide Number 8
905

Slide Number 9
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Slide Number 10
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Slide Number 11
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Slide Number 12
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Slide Number 13
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Slide Number 14
911

Slide Number 15
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Slide Number 16
913

Slide Number 17
914

Slide Number 18
915

Slide Number 19
916

Slide Number 20
917

Slide Number 21
918

40. agnella2_clean
919

Health Literacy and Cancer
919

Slide Number 2
920

Slide Number 3
921

What is Literacy?
922

Background
923

Slide Number 6
924

Example
925

Consequences of Low Health Literacy
926

Health Literacy Model
927

Factors that Influence HL level
928

Tools to measure HL
929

The Newest Vital Sign-Test of Functional HL
930

Slide Number 14
931

Slide Number 15
932

Same for all countries?
933

European Health Literacy Project-HLS-EU 2009-2012
934

European Health Literacy Project-HLS-EU 2009-2012
935

HLS-EU ModelDomains and dimensions of Health Literacy
936

Slide Number 21
937

Health Literacy and Cancer
938

HL and Radiotherapy
939

HL and Radiotherapy
940

HL and Radiotherapy –Ireland?
941

HL and Radiotherapy –Ireland?
942

Slide Number 27
943

Slide Number 28
944

What are the signs?
945

Slide Number 30
946

Can we give information better?
947

Slide Number 32
948

Plain Language
949

How can we check understanding?
950

Slide Number 35
951

Current Study
952

Research Aims
953

Slide Number 44
954

Take home message
955

Slide Number 47
956

41. Implementing and managing IGRT_MK
957

Slide Number 1
957

The Aim of the presentation
958

Protocol implementation
959

Preparation phase
960

Preparation phase: Investigate!
961

Slide Number 6
962

Planning/protocol writing phase
963

Implementation Phase
964

Well described and well defined tasks
965

Anatomical changes
966

Slide Number 11
967

Slide Number 12
968

Slide Number 13
969

Atelectases
970

Slide Number 15
971

Tumor regression
972

Tumor shift
973

Slide Number 18
974

Rare changes
975

Rare changes
976

Change in lymphocele
977

Weight loss
978

Slide Number 23
979

Cardiac changes
980

Slide Number 25
981

Summary
982

How to deal with changing anatomy?*
983

The protocol…
984

Implementation Phase
985

Plan of the day
986

Slide Number 31
987

Demo database ART blaas
988

Implementation Phase
989

Evaluation phase
990

Bladder ART: Safety-net plan selection
991

Conclusions
992

Slide Number 37
993

John Kotter’s 8 steps of change
994

Thank you for your attention!
995

42. WhoIsDoingWhat_DBN16_RdJ
996

Who is doing what in Radiation Therapy
996

Slide Number 2
997

Survey
998

Survey
999

1. Indication of treatment
1000

1. Indication of treatment
1001

2. Pre-treatment Imaging
1002

2. Pre treatment Imaging
1003

3. Delineation: Target Volume
1004

3. Delineation Target Volume
1005

3. Delineation: Organs at Risk
1006

3. Delineation Organs at Risk
1007

4. Treatment Planning
1008

4. Treatment Planning
1009

5. Treatment Delivery
1010

5. Treatment Delivery
1011

6a. Image Guidance: Acquisition
1012

6a. Image guidance: Acquisition
1013

6b. Image Guidance: Registration
1014

6b. Image Guidance: Registration
1015

6c. Image Guidance: Evaluation
1016

6c. Image Guidance: Evaluation
1017

Who is doing what?
1018

RTT training / Education
1019

Training & Education
1020

RTT training / Education
1021

Slide Number 27
1022

Slide Number 28
1023

Slide Number 29
1024

Slide Number 30
1025

IGRT
1026

IGRT modalities: 2D MV
1027

IGRT modalities: 2D kV
1028

IGRT modalities: 3D kV
1029

IGRT modalities: 3D MV
1030

IGRT protocols are
1031

IGRT
1032

IGRT
1033

IGRT
1034

IGRT
1035

Who is doing ART?
1036

Summary
1037

Questions & Discussion
1038

43. Safety issues and prospective risk analysis_MK
1039

HFMEA – Martijn Kamphuis
1039

Introduction
1040

Failure Modes and Effects Analysis (FMEA)
1041

FMEA project
1042

FMEA project
1043

Process Mapping
1044

Slide Number 7
1045

FMEA project
1046

Team
1047

FMEA project
1048

Steps in a FMEA Process
1049

FMEA
1050

FMEA project
1051

Risk Priority Number (RPN)
1052

Example RT Process: Ford et al, 2009
1053

Slide Number 16
1054

Example: Step _x_ in Process: Field Placement
1055

Example: Step _x_ in Process: Field Placement
1056

FMEA: putting it all together
1057

The Workshop (50 minutes)
1058

Process map: Online 3D portal imaging
1059

Feedback session
1060

Conclusions
1061

Thank you for your attention!
1062

45. Incident management
1063

46. WorkshopPS_DBN16_RdJ
1097

Slide Number 1
1097

Workshop on Plan Selection
1098

Slide Number 3
1099

Slide Number 4
1100

Slide Number 5
1101

Plan selection - cervix
1102

Plan selection - rectum
1103

Geometrical uncertainties rectum
1104

Plan selection - rectum
1105

Plan selection – rectum
1106

Plan selection – rectum
1107

Plan selection – rectum
1108

Plan selection – rectum
1109

Design of the study
1110

Design of the study
1111

Workflow registration and selection
1112

Workflow registration and selection
1113

Workflow registration and selection
1114

Workflow registration and selection
1115

Outcome of the study
1116

Outcome of the study
1117

Outcome of the study
1118

Implementation - conclusion
1119

Clinical protocol
1120

Mosaiq
1121

Administration at Linac
1122

Safety net
1123

Slide Number 28
1124

Slide Number 29
1125

Slide Number 30
1126

Slide Number 31
1127

Slide Number 32
1128

Slide Number 33
1129

Slide Number 34
1130

Slide Number 35
1131

ART bladder patient 1 / CBCT 1
1132

ART bladder patient 1 / CBCT 2
1133

ART bladder patient 1 / CBCT 3
1134

ART bladder patient 2 / CBCT 1
1135

ART bladder patient 2 / CBCT 2
1136

ART bladder patient 2 / CBCT 3
1137

Slide Number 42
1138

Slide Number 43
1139

Slide Number 44
1140

Slide Number 45
1141

Slide Number 46
1142

Slide Number 47
1143

Slide Number 48
1144

Slide Number 49
1145

ART cervix patient 1 / CBCT 1
1146

ART cervix patient 1 / CBCT 2
1147

ART cervix patient 1 / CBCT 3
1148

ART cervix patient 1 / CBCT 4
1149

ART cervix patient 2 / CBCT 1
1150

ART cervix patient 2 / CBCT 2
1151

ART cervix patient 3 / CBCT 3
1152

Slide Number 57
1153

Slide Number 58
1154

Slide Number 59
1155

Slide Number 60
1156

Slide Number 61
1157

Slide Number 62
1158

47. AE Reporting and Role of RTT 2016
1159