2011 AAMD Online Continuing Education Modules Descriptions

Module 11-1: Dosimetry Documentation and Coding:Ensuring compliance in your EMR while incorporating the latest requirements

Sally Eggleston, MBA, RT(T); Kelli Weiss, RT(R)(T)

Abstract: This program is designed to educate dosimetrist on the most common areas of concern regarding compliance for billing dosimetry procedures that are documented in today’s most commonly utilized oncology EMR systems. Information will be presented to the attendees that will include but will not be limited to; documentation requirements, physician signature requirements and correct coding methods to ensure compliance utilizing both ARIA and MOSAIQ.

Module 11-2: Creating a Successful Electronic Medical Record (EMR) at Duke University Hospital: Setting Goals and Achieving Them

Kim L. Light, CMD

Abstract: Converting from Radiation Oncology paper charts to an Electronic Medical Record (EMR) is potentially an enormous and costly process. In January 2009, we at Duke committed to converting to an EMR in our department within 1 year. We formed a multidisciplinary EMR team that met on a regular basis to identify EMR action items. We set goals and agreed to achieve these within a specified amount of time. Although our primary goal was to convert from paper charts to an EMR, it was agreed upon that that this would be done only if patient safety and treatment efficacy was not compromised. The EMR team identified all existing paper processes and implemented effective EMR processes. We did this in steps so staff could get used to small changes instead of converting to a complete EMR all at once. Hospital wide data and Radiation Oncology specific data required different processes at our institution. Radiation Oncology specific data was managed with our existing system (ARIA, Varian). In January 2010, all new treatments were managed solely with the EMR. We found the EMR information became more widely accessible although extensive education and training was performed to ensure that staff was using the EMR efficiently and safely. We encountered many challenges in our journey to implement an EMR but believe Duke Radiation Oncology has converted from paper to EMR without compromising patient safety, quality, and patient confidentiality. The cost of implementing an EMR was associated with new hardware and software along with many hours of hard work from a dedicated staff. It is projected that there will be a yearly savings on other items no longer needed that are related to the paper chart. This presentation will describe the process taken to implement EMR in Radiation Oncology at Duke with specific emphasis on dosimetry, physics, and the Radiation Therapist conversion to an EMR. Lessons learned and challenges encountered will be discussed. Creating a successful EMR takes support from all staff, departmental / hospital leadership, corporate IT, and vendors but what seems impossible can be done by achieving one goal at a time.

Module 11-3: IMRT Class Solutions for Treatment Planning of Intracranial CNS Malignancies: Standardized, Efficient, and Effective

Matthew B. Palmer MBA, CMD

Abstract: The use of IMRT is becoming more commonplace in the treatment of CNS malignancies. However, the determination of beam arrangements is still an empirical process, and optimization of the plan may take hours on the part of the dosimetrist and the physician to achieve optimal conformality. Regional CNS class solutions have been in partial implementation at our institution since 2009. Currently, our dosimetrists are free to use individual patient-specific optimization or to use class solutions, which provide predetermined beam angles and IMRT objectives based on the location of the target in the brain. The purpose of this present work was to investigate the validity of class solutions guidelines in clinical practice. The plans of 55 patients treated for CNS malignancies since 2009 were analyzed retrospectively. 30 plans were categorized as having been planned with class solutions and 27 plans - with patient-specific optimization. The categorization was based on whether the IMRT plan for the region treated used the predefined beam angles and IMRT objectives for that part of the brain. Each plan was evaluated based on mean dose to the brain, brain V30, and RTOG conformality Index. Also used for comparison was historical benchmark data from 140 patients treated with patient-specific optimization prior to 2009. Plans generated using class solutions were better than those that were individually optimized prior to introduction of class solutions as well as after. This held true for RTOG conformality index, brain mean dose and brain V30. With equivalent PTV volumes, the class solutions reduced the brain V30 by an average of 7.5%, Brain mean by an average 324 cGy, volume of 30Gy by an average of 157 cc, and volume of 20Gy by an average of 218 cc. The RTOG conformality index for the 20Gy volume was reduced by 0.95.As a whole, individually optimized plans were inferior to those generated using class solutions in terms of mean brain dose, brain V30, and RTOG conformality index. The clinical significance of this improvement is yet unclear. Although the time to complete each plan was not assessed in our study, it is reasonable to assume that the use of class solutions can lead to a considerable conservation of resources for the dosimetrists and physicians in terms of time and staff.

Module 11-4: Dosemetric Challenges and Planning in Veterinary Radiation Oncology

Jimmy Christian Lattimer, DVM, DACVR, DACV

Abstract: Radiation Therapy has become a mainstay of cancer treatment in animals and is now recognized as a separate board certification specialty in veterinary medicine.This is most commonly done with linear accelerators designed for use on human patients. However the variety of size, species and anatomy of veterinary patients precludes the use of any type of standardized treatment approach. Each patient must therefore be individually approached. Some of the more common issues relate to very small size of some patients (less than 4 kg) and the very large size of some patients (>500 kg), the size of the tumor relative to the patient, the presence of very large air cavities in the head of many patients, beam energy relative to patient size, electron dosimetry in sharply angular patients and use of bolus materials in very superficial tumors.These issues will be highlighted and discussed. The major focus will be on use of very small treatment fields in small patients, the treatment of tumors of the head and neck, treatment of large superficial tumors using combination electron and photon plans and the use of bolus materials with highly angular anatomy in small fields. In addition a brief discussion of the dosimetric issues relative to patient positioning and restraint will be discussed.

Module 11-5: The Leadership Journey - From the Classroom to the Clinic

Rocky Barra

Abstract: This 50-minute session will share practical application leadership tips to help ensure a successful and cohesive team. Whether you are a new leader, a seasoned veteran or wanting to step into leadership, everyone will grow in their influence as we unpack and examine principles from the leadership toolkit.

Module 11-6: Intensity Modulated Radiation Therapy (IMRT) Benchmarks and Class Solutions for Anal Malignancies

Mary Pham, CMD

Abstract: Anal tumor/malignancies have been historically treated with 4-field AP/PA/Rt lat/Lt lat treatment plans with boosts to nodal volumes. With the advent of intensity modulated radiation therapy, or IMRT, planning techniques, these tumors that previously constituted large fields are treated with more conformal radiation and doses are escalated due to achievable dose sparing to the bowel, genitalia, and other critical structures that could not be done with previous radiotherapy options. However, there is still a great deal of differences between IMRT treatment planners based on selection of beam angles used, number of beam angles and IMRT objectives used.

Purpose
To develop IMRT benchmarks for anal tumors and in doing so, decrease inter-planner variability by providing a planning framework for IMRT with integrated boost optimization solution.

Methods and Materials
Forty-two patients treated for anal malignancies since early 2005 to late 2009 were retrospectively analyzed. Patients were then divided into 4 subsets depending on the dose escalation tied to TNM disease classification. These 42 patients were replanned using 7-split beam technique and optimal objectives were developed. Each plan was compared to the original approved plans.

Results
The IMRT plans that were generated for benchmarking were better than the previously treated plans. The bowel, once contouring for this structure was standardized, femoral heads, bladder and genitalia doses were significantly reduced with the new beam angles and objectives.

Conclusions
The new plans generated showed much improved critical structure sparing, mainly the dose to the genitalia against the formerly approved plans. Optimization was minimal once the beam angles and set objectives were used. In setting these benchmarks, we can achieve better-quality plans in a faster time frame. In a clinical setting, this would standardize anal IMRT treatments, improve in achieving time constraints, and decrease extra resources used in planning these time-consuming plans.

Module 11-7: Thoracic Planning with Passively Scattered Proton Therapy: A Paradigm Shift

Jaques B. Bluett, MS, CMD

Abstract: In the past half century, we have seen many advances in the treatment of thoracic malignancies with radiation therapy. The standard of care continues to evolve from 3D photon treatment (3DXRT) to Intensity Modulated Radiation Therapy (IMRT) to Passively Scattered Proton Therapy (PSPT) to Intensity Modulated Proton Therapy (IMPT). We aim to share our treatment planning experiences in Thoracic planning with PSPT and the progress we have made in the past few years. Our benchmarking data shows that we can correlate involved lung volume and mean lung dose for protons, as has been done for IMRT (Palmer, et. al.). The evolution of this model, combined with innovative techniques in proton treatment planning, has changed the way we think when approaching these cases. This discussion documents the change in our mindset as we shift from 3D photon to 3D proton mentality.

Module 11-8: Permanent Breast Seed Implant using Palladium-103

Manon Lacelle, CMD

Abstract: Permanent breast 103Pd seeds implant (PBSI) is partial breast irradiation technique that is realized in a single one hour procedure under light anesthesia. A dose of 90Gy is delivered on the planned target volume and this very high dose is equivalent to a standard dose of 50Gy delivered in 25 treatments. Eligible patients include those referred for adjuvant radiotherapy for an infiltrating ductal carcinoma 3 cm in diameter, surgical margin >2 mm, no extensive in situ carcinoma, no lympho-vascular invasion, and negative lymph nodes. With the help of computed tomography, the implant is pre-planned and 2 weeks later the patient is implanted with Palladium 103 seeds under ultrasound guidance. A minimal peripheral dose of 90Gy is prescribed to the CTV identified on the CT scan plus a margin of 1.5 cm. A month later a post plan is done with the help of a new CT scan. This permanent breast seeds implant (PBSI) technique has been tested in a prospective Phase I/II trial and is currently offered in a multicentre Registry trial. Since 2004 we have performed more than 80 permanent 103Pd seed implants on early stage breast cancer patients. I will discuss the procedure, the quality assurance aspects, the dosimetric factors, the patients satisfaction as well as treatment outcomes and side-effects.

Module 11-9: A Review Of QUANTEC Normal Tissue Tolerances

Mary Lou DeMarco, MS, CMD, RT(T); Thomas Dilling, MD

Abstract:
Purpose: To evaluate impact of FDG PET CT in target volume definition, in inter and intra observer variation in target delineation and on tumor and normal tissue dose variations.

Materials and Methods: Fludeoxyglucose positron emission tomography (FDG PET) combined with computed tomography (CT) has been shown to have greater specificity and sensitivity than CT alone for diagnosis and staging of non-small cell lung cancer (NSCLC) patients. In this study, twenty patients had CT and PET imaging as part of their treatment planning which was performed using pencil beam convolution algorithm with tissue heterogeneity using Eclipse from VARIAN. All treatment plans used multiple non-opposing co-planar beams of four to seven fields. The prescribed dose was 70.2 Gy in 39 fractions.

Two physicians (TH and ST) independently delineated tumor volumes, and treatment plans were generated for each set contoured by them. The doses to the CT contoured structures were obtained from plans that were originally planned based on the contouring of PET-CT fused images for each patient. The tumor volumes defined by PET-CT and CT alone were compared in terms of concordance index (CI) which measures the difference that PET-CT introduces in the target volume definition. The intra and inter observer variations on tumor delineation were calculated. The mean, minimum and maximum doses to tumor and normal tissue complication probabilities for lung will be presented.

Results: The mean intra observer concordance index was 0.48 (range 0.20-0.83) for physician ST and 0.50 (range 0.20-0.76) for physician TH. The mean inter observer concordance index was 0.45 (range 0.12-0.70) and 0.52 (range 0.24-0.81) for CT and fused PET-CT tumor outlining respectively. The tumor and normal tissue dose variations are being evaluated and will be presented.

Conclusions: The use of PET-CT in patients with localized lung cancer significantly changed target volume created by the two experienced radiation oncologists, while pathological verification of PET-CT defined tumor volume was not part of this study; several recent papers suggest clinical correlation with PET-CT clinical tumor volume. Thus, use of PET-CT to define high dose radiation treatment fields represent current state of the art.

Module 11-10: Lessons Learned from the Review of Brachytherapy Implants for Cervical Clinical Trials

Franklin Hall, BS

Abstract: The Radiological Physics Center (RPC) has reviewed brachytherapy doses for the national clinical trial groups since 1968. The purpose of this review is to assure the clinical trial groups that the data reported is correct and comparable between the institutions placing patients on trial. During this time period the RPC has reviewed over 3000 high dose rate (HDR) and low dose rate (LDR) implants for cervical trials. These implants are submitted by hundreds of different institutions. In order to provide consistency for the trial, each implant undergoes two reviews, a clinical review and a dosimetric review. The clinical review is performed by the radiation oncologist PI on a given study. The dosimetric review is performed by the RPC.

The RPC performs an independent recalculation of the doses reported for each patient. The study group provides the RPC with the brachytherapy dosimetry data including source activities, dwell times, dwell positions, isodose plots and orthogonal implant films or an electronic set of DICOM CT slices for each implant submitted by the participating institution. The RPC recalculates each implant using the specific treatment times for a patient and compares the RPC's dose to the institution's reported dose using an acceptance criterion of ±15%. If the RPC agrees with the institution's reported dose, the dose reported by the institution is accepted by the study group. If the RPC disagrees with the reported dose, the RPC works with the institution to understand and resolve the difference seen. The resulting corrected dose is then reported to the study group. This allows the study group to have consistent and correct data for their trial.

Over the years, the RPC has detected numerous errors in the calculation and reporting of brachytherapy prescription doses for required protocol calculation points. The errors observed are both random and systematic and range from >5% to over 100%. A detailed description of the location of the protocol prescription points for brachytherapy patients is presented along with a discussion of common errors made in defining and reporting doses to these protocol prescription points.

The investigation was supported by PHS grant CA 10953 (NCI, DHHS).

 

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