The Applicability of OSMS for Extremity

Positioning
Haylee Cross
 Intro to OSMS

• OSMS= Optical Surface Monitoring

System
• type of SGRT (surface-guided radiation therapy)
• Uses camera and computer system to
topographically map the patient’s surface in real-
time and overlay it with a reference surface
• Green= reference surface from CT sim
• Purple/pink= present patient’s surface
• Can track and display external motion in real time
which can be used to guide the patient into position

• Intentionally created for and most commonly used

for….
• Breast patients
 OSMS Equipment and
System
• Three mounted cameras mounted to
ceiling in the treatment room
• Speckled, infrared lights shine over the
patient, allowing the computer system to
topographically visualize the patient’s
surface
• Software system utilizes two computers,
one inside the treatment room and one
next to the console, converts data from
cameras in order to digitally reconstruct
the patient’s surface
 OSMS= Optical Surface
Monitoring System

• Using the captured surface from

their CT simulation day, OSMS
can:
 Give a real time comparison of the
current patient surface vs. their
surface on CT sim day
 Recognize and classify deviations in the
setup into 6 different planes/directions
of movement to aid in setups
 Customize (with physician’s orders) the
acceptable ranges of deviation for a
patient and/or for each type of
movement
 Ex: +/-1° for rotation, but only +/-0.75° for
pitch
Other advantages/capabilities of OSMS
Advantages
 Beam gating
 (Ideally) quicker setup
 Immediate info regarding
patient setup (vs imaging)
 No extra dose to patient
 Get SSD’s without going in
the room
Disadvantages
 Requires $$$, installation
and training
 Gantry can obstruct cameras
and cause incorrect readings
 Additional QA
 Cannot account for large
changes in patient anatomy
(weight loss, swelling, port)
OSMS Potential in
radiation therapy

Created with intent for breast cancer patients

Great for treatment sites that:

• Are mostly external/superficial

• Are shallower and lack depth
• Have unique/identifiable characteristics that OSMS will
easily be able to track

Are there any other treatment sites with

similar criteria that might benefit from OSMS?
• Extremities?
• Head and neck?
OSMS for extremity positioning
• Extremity setups are particularly
challenging
• Excess ROM in multiple planes
(especially for upper extremities)
• Lack of standardized immobilization
equipment
• Difficult to index such an off-set target
• Pain and/or mobility issues
• Extremity patients often have to
deal with:
• Repeated imaging procedures
• Frequent repositioning
• Lengthy treatments and time spent
on the table
Study #1: Is OSMS reliable?
• In 2015, a study was conducted on a newly installed Truebeam Edge at the Humanitas
Center. The study tested the positional accuracy of OSMS using a head phantom.

Test What aspect of OSMS was being Results

Number tested?
1 positional accuracy of OSMS vs CBCT - Differed from CBCT linear axes by 0.6 ± 0.3mm
isocenter - Maximum couch rotation error of 0.3˚
2 OSMS ability to recognize shifts up to 2˚ and - Shifts = 1˚and 1cm: capable of 0.3mm accuracy
3cm - Shifts > 1˚ and 1 cm: capable of 0.5mm accuracy
3 OSMS accuracy at varying couch angles Couch angles of 45˚ and 90˚ had a mean uncertainty <0.4 mm

4 OSMS ability to reconstruct patient’s surface One obstructed OSMS camera yielded an uncertainty of <0.5 mm
while gantry is blocking one of the cameras

Conclusion: The study found that OSMS can accurately detect translations and rotations of
the head phantom and is positionally accurate.
 Study #2: How accurate is OSMS?

• In a 2021 study, breast CA patients Surface # of Surgical % of

receiving radiation to their tumor
bed were setup using OSMS to be Matching Clips Conincidence
verified using IGRT with the Values with IGRT
patient’s surgical clips as a
reference point for accuracy >95% ≥3 99.7%
• 252 patients enrolled, 1170 setup
verifications performed, utilized >95% all 92.5%
Align RT and exactrac
>90% ≥3 99.5%
• Results:
SGRT improved patient setups by
a mean of 5.3 points (from 92.7% Conclusion:
accuracy to 98%) when compared • Improves patient positioning accuracy, OSMS can
to a three-point setup accurately localize the tumor bed, eliminate
unwanted radiation from the IGRT process
Study #3: How is OSMS currently
being used clinically?

• In a 2019 survey, of 439 participants,

53.3% said their department has surface-
guided technology and 48.8% said their
department had plans to purchase such
equipment in the next 1-3 years
• The data collected for OSMS usage during
initial positioning per treatment site
reported is as follows (in order from most
to least common):
• Breast> SRS> SBRT> lung> head & neck>
extremity> GU/prostate> pediatric> other
• A poll was run regarding how often the
participants used imaging to verify
extremity patient setup
• 47.3% daily, 40.2% weekly
Study #4: OSMS for positioning extremities

A review of surface-guided radiotherapy published in 2018 analyzed the following

aspects of OSMS specific to the treatment of extremities

 Challenges with extremities: decreasing dose to normal tissue, difficult reproducibility requiring
Reviewed the goals of larger margin, immobilization uncertainties
 Goal: decrease setup error, decrease treatment margin and decrease verification imaging and
OSMS imaging dose

Gave feedback on  Current systems lack the ability to relate topographic surface data to internal or
commercially available bony anatomy, meaning verification imaging is still common to confirm internal
surface imaging systems targets

Provided an overview of  OSMS has the potential to make setup errors known to therpists before they exit
SGRT applicability by the treatment room and without giving the patient any dose
treatment site  Decreasing amount of time the patient is on the table

Discussed any limitations  Conclusion: In the future, SGRT will continue to contribute to decreased daily
or future applications of imaging procedures for extremity patients as well as decrease the need for
SGRT repeat images
 • How will it be executed?: The patient
• How willwill
it be
beexecuted?:
divided intoThe
My Study population
patient population
treatment group thatwill
a
willbe divided
utilize OSMS
forinto a treatment
daily setup and group thatgroup
a control will which
utilize
will OSMS
utilize for dailytriangulation
traditional setup and a
controlfor
methods group which will utilize
setup.
• Purpose: evaluate the ability of OSMS to •traditional
The shifts triangulation methods
resulting from imaging >1.5 mm
decrease unnecessary patient exposure from forshould
setup.be noted in the study and the images
excess imaging procedures caused by • revised
The shifts resulting from imaging >1.5
challenging setups • Images shouldbe
mm should notnoted
be aligned
in the in a way
study andthat
results in largerevised
the images splits with anatomy, but
• rather centralizing
Images should notthe betarget
alignedin in
the PTV as
a way
• Population: best as results
that possiblein large splits with
• study will consist of 500 participants (no anatomy, but rather centralizing the
restriction on diagnosis, age, sex, etc) • Results: Theintrial
target the PTVwillascompare the
best as possible
• participants must be receiving photon • Results:
number of The trial will
repeated compare
images the the
between
radiation to an extremity number
two of as
groups, repeated
well as images
the total imaging
• treated without 6DOF between
dose theoutside
received two group as well
of what wasas
• a standardized PTV margin of 3 mm the imaging
prescribed for dose
each received
dose outside
• receiving daily imaging, either KV/KV of what was prescribed for imaging
orthogonal pair or CBCT daily
References

1. González-Sanchis A, Brualla-González L, Fuster-Diana C, et al. Surface-guided

radiation therapy for breast cancer: more precise positioning. Clinical and
Translational Oncology. 2021. doi:10.1007/s12094-021-02617-6
2. Mancosu P, Fogliata A, Stravato A, Tomatis S, Cozzi L, Scorsetti M. Accuracy
evaluation of the optical surface monitoring system on EDGE linear accelerator in
a phantom study. Medical Dosimetry. 2016;41(2):173-179.
doi:10.1016/j.meddos.2015.12.003
3. Padilla L, Havnen‐Smith A, Cerviño L, Al‐Hallaq HA. A survey of surface imaging
use in radiation oncology in the United States. Journal of Applied Clinical
Medical Physics. 2019;20(12):70-77. doi:10.1002/acm2.12762
4. Hoisak JDP, Pawlicki T. The Role of Optical Surface Imaging Systems in Radiation
Therapy. Seminars in Radiation Oncology. 2018;28(3):185-193.
doi:10.1016/j.semradonc.2018.02.003