Patient positioning and immobilization

techniques
for radiation therapy

Vivek Yadav
Technologist
Dharamshilla Narayana Hospital
Patient positioning, fixation and reproducibility of setup

• Whether you are doing conventional radiotherapy, 3D

conformal or IMRT, IGRT,SBRT,SRS,SRT AND VMAT
treatments- accurate, reproducible positioning and rigid
fixation are important factors for precise dose delivery
to the treatment portals.
• Thermoplastic shells offers a reliable method for
accurate positioning and immobilization.
acrylic material or carbon fibre. Available for head
• There are three essential components required for
making these shells.(i) Base plate: made up of
and neck cases, chest, pelvic regions.
(ii) Neck supports: foam type poly urethane material or silver
man standard supports.
(iii) Thermoplastic masks.
 What is patient immobilization?

a reproducible localization of the patient with a device

into which the patient is locked, to aid in the restriction
of anatomical movement
Why to use positioning and immobilization
devices?

increase target accuracy

easy to use
quick to set up
comfortable for the patient
durable enough to withstand an entire course of treatment
What is patient
positioning?
a reproducible
localization of the
patient with the use
of
a device onto which
a patient lays a
specific part of their
anatomy
 History of patient positioning
FROM THE START OF 19TH CENTURY TO 21ST
sand bags
tape
bite block
plaster casts
“home-made devices”

In 1896 a German physics professor, Wilhelm Cornrad Roentgen,

presented a remarkable lecture entitled COCERNING A NEW KIND OF
X-RAY and soon after within a month system were being devised to
use x-ray for diagnosis and within 3 yrs radiation was used to treat
cancer. 1901 he was awarded the First Noble prize
Considerations for selecting a device

cost
convenience
accuracy
compatibility
attenuation
durability
Positioning and immobilization devices must be ..

comfortable to minimize movement

reproducible for the treatment plan

Consistency

Consistency in patient positioning and immobilization

from treatment planning to simulation, and from
simulation to treatment must be maintained.
 verbal statements to
immobilize patients
1. ONLY INVOLUNTARY MOVEMENTS, PLEASE.
2. HOLD VERY, VERY STILL.
3. LIE QUIET
4. BE MOTIONLESS.
5. LET A CALM FALL UPON YOU.
6. NO MOVEMENTS, PLEASE.
7. PLEASE DO NOT MOVE.
8. DON’T WIGGLE, NOW.
9. LAY HEAVY, BECOME AS ONE WITH THE TABLE.
Head and neck positioning
and
immobilization
Challenges of the head and neck region

neck extension must be controlled

claustrophobic patients
inserting bite blocks or shunts in a
thermoplastic mask
reproducibility of daily setup
Current methods for positioning and
immobilization

Thermoplastic mask of the head and

head and shoulders ,chest or thorax mask
and pelvis mask Vacloc
Treatment chair
positioning aids
BASE PLATE OR BASE BOARD OR AIO
HEAD CUSHION OR HEAD REST OR TIMOS

B D A

C E
 Thermoplastic masks
Thin sheets (usually 1.6mm to 3.2mm) of solid or perforated
plastic sheets bonded to a rigid frame water
o
temperatures for
perforated thermoplastic must be 60 –65 C

PERFORATED MASK
UN PERFORATED MASK RIGID FRAME
 Abdomen pelvis
Head and Neck

Thorax Abdomen Head

Top 9 Uni-frame® tips

Set up your warming pan with 2”-3” of water and heat

to 165° F. Use a digital thermometer to check the water
temperature. Do not overheat.
Place the baseplate on the treatment table with the
appropriate head and neck support.

Apply a light coating of baby oil or other lubricant to the

side of the mask that will contact the patient’s face to
keep thermoplastic from sticking to skin, hair and head
rest; apply to entire surface.
Top 9 Uni-frame® tips

Place the Uni-frame into heated water , until

thermoplastic turns clear (1-3 minutes).

Remove Uni-frame from water and shake excess

water from holes; this should be done quickly, before
mask begins to harden.

Center the Uni-frame over the patient’s face; starting

under the chin, gently pull the mask toward you over
the face and head and down to the baseplate. Align
holes in the frame to pins in the baseplate; lock clamps
to frame.
Top 9 Uni-frame® tips

Gently mold soft thermoplastic material to patient’s

facial contours (eyes, nose, cheeks, etc.) to form a
mask. Total working time is 2-5 minutes.

As the thermoplastic cools, it returns to its original

white color and becomes rigid. Allow to cool
completely! Removing the mask too soon will cause
additional shrinkage, and a too-tight refit.

If desired, the thermoplastic can be cut to create

treatment portals after the mask has hardened. Cut
with a cast cutter
 Head and
shoulder
thermoplastic
mask
designed to provide maximum head and upper body fixation by capturing

the head, neck, and shoulders under a continuous thermoplastic sheet

Benefits of thermoplastic mask

economical
disposable
can re-use PVC frame (with re-loadable systems)
markers can be placed on the mask rather than the
patient
reproducible positioning is achieved
Treatment chair

comfortable, reproducible
positioning for patients who
require
vertical positioning

accurate positioning for

claustrophobic patients

reclining back that adjusts

to six positive-locking
positions
Benefits of the treatment cha

can accurately re-position claustrophobic patients

can choose “arms-up” or “arms-down”
can use thermoplastic mask or thermoplastic bra support options
Limitations of the treatment chair

large device may be difficult to store

there isn’t a large percentage of patients who will require this type
of positioning
Positioning aids
Positioning aids

Timos
Positioning aids

Timos
Positioning aids

Timos

Silverman
Positioning aids

Timos

Silverman
Positioning aids
shoulder retractors
Positioning aids
shoulder retractors

bite bock
Positioning aids

foam wedge
Positioning aids

foam wedge

prone pillow
Positioning aids

foam wedge

prone pillow
Benefits of positioning aids

work with positioning devices to increase stability,

comfort and reproducibility
Breast and thorax positioning
and immobilization
Old &Current methods for
positioning and immobilization

wingboard
breastboards
thermoplastic sheet immobilization
lungboard
two-part foam
vacuum cushion
 Wingboard

polycarbonate material with head and

arm rests

designed to fit through CT scanner,

used for both treatment and diagnostic
imaging procedures of the thorax,
breast and lung
 Benefits of wingboards

patient can rest arms and elbows

comfortably
designed to fit through CT scanners
can be indexed to various breastboards
 Breastboards

primarily used to elevate the patient’s

upper torso above the treatment couch
to bring the sternum parallel to the table

creates a uniform surface dose

distribution across the treatment area
 Breastboards

acrylic
composite
carbon fiber
 Thermoplastic
breast immobilization

thermoplastic breast support system

used in conjunction with a breast board

side-mount or back-mount handles

attach of the breastboard
Treatment brassiere
 Treatment brassiere

plastic material
attenuation factors similar to a Silverman

reshapes the ipsilateral breast

reproducible setups

reshapes the contralteral breast to

move it away from the beam
 Benefits of the
treatment brassiere

reduced dose to lungs, heart and ribs

shape and position are reproducible
All sizes of cup sizes are available
eliminates mammary folds
marks can be made on the device and/or
patient for re-alignment
 Lungboards

Primarily used to for lung treatment,

however, it can be used for other
treatments where immobilization of the
upper torso and arms-up positioning is
required.
 Benefits of
breastboards and lungboards

brings the sternum parallel to the table.

simplifies treatment set-ups

eliminates skin folds

 Vacuum cushions

bead filled polyvinyl or nylon-reinforced

bags
Benefits of vacuum cushions

cost-effective
re-usable
quick to set up
full range of sizes
treatment portals are available
safe to set up
longevity is dependent on care and use
Limitations of vacuum cushions

vacuum or wall suction is required

storage space is required
may puncture or develop leaks
can not “cut-away” into the cushion
 Thermoplastic
positioning devices
 Thermoplastic positioning
thin sheets (usually 1.6mm to 3.2mm) of
solid or perforated plastic sheets
cross linked linear polyester softens in
warm water
water temperature for solid
thermoplastic must be 150oF
water temperatures for perforated
thermoplastic can range from 160oF
to 170oF
HipFix
 Benefits of thermoplastic
positioning devices

can be used with prone or supine treatments

exact cast negative of patient anatomy provides
precise reproducibility
marks can be made on the thermoplastic rather than
the patient
portals can be cut out of the thermoplastic
can be integrated with vacuum cushions for
increased comfort and accuracy
 Limitations of
thermoplastic immobilization

thermoplastic sheets are expensive

technique sensitive application requires
hands-on training by vendor
must have a large water bath
Integrated
immobilization
Integrated
positioning and immobilization

combining several positioning or immobilization

devices to adequately position a patient
Thank you