 So, this is my second lecture, it is patient immobilization and set up verification that is actually is connected to my first lectures, here it is a part of conformal therapy of course, it is a very very important part of IMRT and IGRT and everything and try to give you some aspects, oh here is a possible, we explained earlier the correct dose of radiation shall be delivered just to the target PTV in our case and the dose to surrounding structure shall be as low as possible, not only the organiatrics in other normal tissue surrounding the PTV we should also save it and must be achieved or many occasions this important 30 times, at least 30 times every day. Therefore, it is better you have immobilization devices you put it the patient and every the same setting you do not need to contact the patient so please be ready why you are moving like this. So, for the organizing organization here it is easy for you and it takes less time but when you without the immobilization you should every day the preparation here it takes a long time. So, it is not only the repetition of uncertain the to omit the uncertainty, but it is actually you are working also quicker this actually important and it must be very feasible, very variable must be documented in a way that allows other to understand all important factors of the treatment performed some 30 years also we should understand. So, here actually the contents what I am going to deliver here the source of uncertainty methods to verify the dose customization of the block and patient positioning immolation devices actually I can also do the both first and then the verify you do everything on the final check it can be done. These are the sources of uncertainty I have taken these slides from the IEA you can also download take it is also from my I will put it also the desktop and you have everybody this one not a problem it is a patient localization organ motion yeah you have many, many repetitions yes amazing is also and source of uncertainty definition of anatomy, beam, geometry, dose calculation, dose decision plan evolution and plan implementation all the sources of uncertainty. So, we start one after another patient localization you see the patient should be positioned identically during the diagnostic city simulation and 30 times during treatment the all are the same positions this is actually a challenge but we have the possibility to do that we should be care and aware of that and source of uncertainty we have also learned motion the ability of the mark on the skin and course set sometimes also possible that is why every day you should understand of the 100 centimeter source of everyday check it may be always and actually it is the technician therapy technician because medical phase should have a very good relation with this sometimes it is not so in Germany they have more relation with the medical doctors but you try to have also a good relation with them because they are always 8 hours with the patient yes and on medical doctors and faces occasionally there so actually they knows the daily problem and you have good relation so they inform you the problem and everything so you are aware of the whole therapy situation yeah this is very important don't actually yeah the faces they are looking for the medical doctors because they are husband yeah and you only excited him so equal but should be also cook the back is important yeah not just like a car you put it back to mirror and then you forget the back mirror is not good so it's always your attention in the back is important so you have organ motion yes different types sometimes in different position organ motion here affects most organ particularly noticeable for lung cancer liver prostate and other pelvis maculancy yeah it's very difficult to control that's why in these cases the MRT is also escalation this is so not so easy so the people started MRT from the head mama on like this but more the develop the devices we start also with this here the image issues yeah this is actually also for us important to understand the image especially from scanning images yes when you see here also a problem and we should also have this problem and it takes also uncertainty and here the target definition out like organs yes we have discussed everything yeah the microphone is crashing I hear oh you are the expert okay thank you yeah target definition here here just you see just a moment here are the seminal vessels really where they are drawn here yeah they are the medical doctor can understand yeah in the older time as I am the beginners in Heidelberg in Germany there are some old doctors here who come with the plan to them and there's a old man is a very famous he told me this is not the case when they pass me my places and so here here is this one and just there are more vibrating his hand was told but these people knows actually in who is case organ is in these places so they should know the anatomy and the movement so there it is not easy for the medical face is also not on our tax but it is a source of uncertainty and here you cut the blocks yes and how can you cut the blocks when there is a simulator projection x-ray and you draw the and you cut the blocks and you put in the real position in accelerator you have exposed once again and see the real situation or not this is another source of uncertainty when always there is a gantry set yeah not because the patient is very thick maybe it's actually the geometrical problem sometimes you have passion 250 kilo then you have no problem then put it in the floor and edit it yes it's not a joke yeah we have the a course in linear accelerator maybe 165 kilo but we have more than 165 kilo patient it is the effect of fast food maybe so here dose calculation it is also important you know this modality dose calculation we must aware actually the algorithm yeah the limitation of algorithm you can read actually the publication yeah medical faces should also not overcome his daily problem but he should also a scientist yeah a good scientist he should publish publish something so you read always yeah you're in a hospital at least two or three international journal should be there yeah talk with the medical doctor not all the journal from the medicine not from the physics but now you have also the possibility direct to the internet and download it yeah we have this you know the european they have also a very good journal green journal no this is from the medical doctor that we have physical medica you know this physical medica this was a very good and in american you know the medical physics even india they have also very good and very cheap you can the live member with 200 dollars and you can have the whole life the journal of medical physics from india they are very very practical practical applications and practical journal and you can also have this one and so many and many and also we have been a form they have formed from maloesia they have also electronic medical physics journal yeah as we should read always yeah the medical physics should read at least two hours per day publication have you time enough after your finish your work in the hospital so actually the information update yeah update what is who where i find something when i have some problem where can i find something the first dates you have a good relation with your colleagues you have your society you can ask your you have better than an odd time your facebook yes on everything you can then done but you know the source where can i solve my problem where can i have the literature where can i help yeah this is actually the importance and very quick help oh the algorithm is yes some algorithms is there every limitation the algorithm yeah you know the convolution is maybe in pencil beam can the pencil beam calculate in electron beam no maybe in head and neck it's a deviation 10 to 20 percent so the doctor do not knows you know that's yeah after the nose there is a some hot spot it cannot be calculated so you know all the details so you can actually give the medical doctors the clear information so can the algorithm and this is the limitation please take it in consideration this is you are the advisor of the medical doctors so the publication reading and information you are the when you have more information more knowledge than you are actually the man of all times so the comparison quantitative plan we can comparison it's can visually it can quantitatively it can qualitatively everything is possible and data terms from it is another actually the text computer pacman as a computer details how the data managing yeah some faces to all generation like me is not easy yeah but you are always with them grown up with the computer yes so you can understand the server how can you manage it you cannot always call the call the vendors biomedical engineering it's easier to understand is the data is coming okay or not that's why is the comic commission time you have some reports and some documents and you can always compare it this just like a quality quality control of tps yeah these are all the you see in medical is a very important person actually in the whole therapy situation yeah I do not I like to overestimate but sometimes I think yeah after the follow-up the patient the doctor had more but in the other chain you have more responsibly sometimes yeah for the banker for the design the department dosimetry for installation everything in your your places yeah and you should be also be convinced this is my position when I should had the capacity to do that people should respect me and and I cooperate with them but sometime overestimate is not good because in a hospital you are not the first man the patient come to the doctors I know doctors call you and go to the patient otherwise when they do not call you cannot come to the patient so you are convinced about your position when you know your position you can handle it better yeah even in the in the first stage in Germany some medical physicists they are too much fed up when they are mad do you know this they're mad because they think I'm the best student of my classes I can better mathematics than the doctors I should be the best man in the hospital so when they have some conflict like this when they are mad they have changed this profession so your position you know and you handle it with this whole team then you have a very very good good places there you should be happy with your places not if he'll always burden yeah then please change your profession why but have the medical physics so it is challenging and you are the person who actually bring everybody together yeah from the administration medical doctors technician and vendor yeah you are the person they bring don't actually when you have some difficulty is a medical doctor don't say then vendors I have difficulties me doctors when they know then you have the difficulties in doctors the vendor come to the medical doctors not through you because he thinks then he's actually the main person if they have the problem so I go to the medical doctor so you sometimes do not know what is in hospital is going on so you should solve your problem your own experience and you should be clever enough so here the does the transfer and here there's a good the plan looks great however one must ensure that during treatment everything matching the plan this is the variation of the delivery here once again this is at behind this actually very important I cannot tell you more than him always there's the positioning is very important in all places yeah what you calculate in tps this is actually the central and so should be done everywhere here the most important comparison yeah you have actually the port film and repeat the both you know when here is a simulator film and drr every one of you in the hospital in repeat order you have some port film also epi epi yes yeah everybody yes yeah yeah I have a good experience in port film when you introduce your foot film ask me this is the old generation but it was that time is very yeah the because the because you know when the radiation low radiation better contrast you know the x-ray it is actually the from the nature when have low voltage you have better contrast high voltage contrast is diminishing therefore you have seen always a very good radiograph of mouse have you seen a radiograph on elephant no so a slim people have better x-ray picture thick one is bad so actually this is the question is the this the diminishing the contrast so at that time even in this time some devices is given dupo film dupo there is a factory and some steam cassette we put it and we have done the contrast and you can the bit the image is very diminishing but you can understand in which place is actually the irradiation places when here is also important with the film you have here is the irradiated field when here is the surrounding that means you have one times a right field and make it larger fields so can you can compare of the anatomies there and actually it is a less radiation maybe 3 or 5 5 monitor units yeah you can neglect it or you can recalculate it from your treatment plan so you give less it is all possible yeah in physics is not is a robust it is a very very fine 0 0 0 1 yes therefore you should not think about the medical doctor yeah sometimes it is his puzzle because you have done very thing is minimum when medical doctors do that don't see their fingers they are responsible for that when you sometimes took their finger then you are puzzled why should I do that no it is their responsibility they do the science like this and you like the science things so here is cooperation and both are same responsible in Europe in Germany no plan without the sickness or of medical physics cannot be done it is one of the specialist of medical in the medicine who you are actually through the yeah sometimes the medical doctor head of the department you are not the head yeah what should we do you are afraid of him no from the radiation protection you have the same same ability in same rights yeah you are clever enough to do that yeah no fighting yes because the legal on your time in Germany when there is a radiation you can go only 15 minutes yeah you can go maybe you in the city to brings your letter and in between 15 minutes when they recall you should come to the hospital otherwise they stopped the radiation because the medical physics is not there yeah so your responsibly is legal yeah actually going not in radio therapy we are trying it is also extra diagnostic nuclear medicine yeah when the nuclear medicine in medical physics mostly is a huge aspect but most this radio therapy is the most application 80 percent physics what in radio therapy oncology and nuclear medicine 10 percent and radio diagnostic maybe 3 or 2 percent and radiation protection and administration and radiation biology all the branches you are medical fix physics exist yeah here so here put film you are put actually in the cassette just in the coach and here is the collimation and everything so repeat yeah this is actually one of the most important here actually you the real in the irradiated machine the real position to control the real position and it's compared with the treatment DRR but here is another tax is very important also you when you read the publication the people are trying to dosimetry with this you know the in 3D conformal therapy we have not patient dependent quality control you know this yes because you have machine added quality control we do the TPS quality control on everything but in IMRT for every patient you should do the quality control this you know this is the difference yeah every x y patient I have quality control and then treated but in conformal therapy no I have some routine and do that and after then it can come any patient so the IMRT is very intensive when here the EPID is actually important so we have a phantom and phantom we put the treatment plan again in the phantom and verify it and compare with the first yes yeah but when you can compare directly in EPID so EPID signal should be translated in doses then we have the best devices but it is not done many places they are trying they are doing some experimental but not in commercially I have heard the factory ELECTRA they are just offering in this EPID the dosimetry then you do not need any phantom on what is more important not in the single places in 0 degree but in any angle you can control it so it is a challenge it should be solved and I hope it will solve very soon then the EPID is everything is there you do not need any other phantom the real vivo patient the dosimetry and quality control we have done some master thesis phd thesis which student yeah but they are locally and after the finishing PhD we do not apply it because the question is that you know then problem is the solution but it should be commercially otherwise it's not so easy to to apply yeah we understand this possible but I think ELECTRA yeah you can say the ELECTRA maybe they have and they should integrated in the EPID so the verification system so here electronic devices yeah this advantage yeah I do not explain anymore it is in every angle and during the passion many times in film is not possible you should change the film and so that's why actually many many importance is a very important part of linear accelerator the EPID yeah here verification film at least course one sometimes in week it's possible on location verification and it should not be the treatment planning geometry for the IMRT on arc you should verify for single field so verify the dose delivered to the patient yeah this is actually the thermoluminescence dosimeter we use it in brachytherapy sometimes actually it is a very good very good dosimetry art you do not need any cables so you do not destroy the daily practice you put the TLD in somewhere and after that you can determine the dose you know the everybody TLD TLD is actually very popular but TLD is actually the advantage you radiate it after many times later hour later you can calculate it here it is actually the poster dosimetry the IA they sent all over the world and check it even in a country like Italy on Germany we have every two years to control our dosimeter yeah the calibration of dosimeter then the central position they sent the TLD everywhere and you irradiate it with the same condition like your ionization chamber and send them back and they they calculate it and send you the results and it should be less than 3 percent less than 5 percent should consize the value of TLD and the linear TLD and ionization chamber when more than 5 percent you should search why yes and then change some procedures on like this on on more than 5 percent you cannot prescribe dose to the patient yeah you can do that this verification yeah but not the control of calibration you can put it yeah you can put it everywhere you can put it yeah also in the mouth nose yeah in the head and head and neck treatment yeah can we TLD dosimetry then we need two hours again the discussion here but when you are one time expert you should have a physics technicians yeah physics technician have you been physics technician department you have 10 faces no physics technician yeah this is a good problem you try to have a physics technician your department just like medical technician yeah then you can put the responsibly he understand he has the feelings he has the experiments and he can give you plus minus 1 percent accuracy but you are facist or no experience no feelings then you make many many failure many many problem mistakes yeah sometimes I have had some physics assistant they take the TLD and sleep with them so they understand they want to hear what the TLDs are talking so these are the these are reports 24 so why do Vivo dosimetry just like you are telling why this is the Vivo dosimetry we do that that the where here this TLD is the most important and naturally the MOSFET radicrome film and others algae in gale geometry as a dosimetry is many many possibilities you are doing this yeah then the then the exit or a dose some hospital they are trying also exit dose yeah these are possible we are doing not have no experience with this our exit dose is also very important it's coming maybe sometimes the regulation that we should determine the exit dose once again here you have heard in the first lectures the PTV and you see the PTV treatment setup passion motion degree treatment organ tissue so when PTV is a geometric concept we have told and here is important the PTV depends on the precision of tools yeah the PTV you draw the PTV and it is actually dependent on the immobilization device and laser when a very good immobilization is laser and perfect then you can draw PTV less yeah PTV is not include margin margin of dosimetry characteristics here you ask here the penumbria area and build up reason so these will require additional margin during treatment planning or shielding devices yes when here is the technical margin can be reduced improving daily setup speed CTV ultrasound yeah you have also today's possible ultrasound scan yeah in the in the brachytherapy picking this is one of the option ultrasound yeah it's a very good option also for radio therapy and once again as you note the biological margin on what I have here written a small reduction of margin can affect on the volume of normal tissue that are exposed the ability to limit the volume of normal tissue in some instances may allow higher dose to be delivered in the probability of two more control when you have only 5 millimeters and you calculate it the whole volume yeah it is a heavy mass maybe 500 centimeter cube so you can save a lot of normal tissue so customization I go you know the customization block some cases we should also customize at that our time in customized block is a heavy tax yeah whole day people are doing customization we have not enough manpower so we select manpower the people the home people they do not go to the war training so they come to in the hospital and do one year training and we allow them to do that customer block I do not go to details so you cut the store door and put it the mcp melting and you can place it yeah now now is then actually the mlc is take the place of blocks but sometimes yeah ready blocks here on that mcp mlc is not possible so this yes yeah so here is the blocks and intensity modulation do you know the physical intensity modulation yeah the older time we have been a physical compensator yeah you have you have cities in the area and out of city you calculate the water equivalent depth and the maximum depth you calculate the rest one so you have you have some compensator and put it in the just in the head of the linear accelerator and so in the middle of the patient you can apply the same dose everywhere so you have you use your monitor table this is done by today in the IMRT IMRT is nothing is a actually is a compensator a modern compensator here here you do the same so that you replace the same dose and then collimation you know collimation the applicators in electron you know everybody the electron had always collimation and late blocks can be much and then multiple collimeters multi leap collimeters now last but not least the patient positioning immobilized devices the best commission does not help if the patient is not stable need good immobilization devices need to put patient in a compatible position this is often difficult with very sick patient yes and need to make the field compatible yeah always these are the mobilization devices so here actually the situation and immobilization max related to the position you can actually the mark in the skin as well as in the in max both on the both consights then everything because in skin sometime it's moveable it come to other position but when there is confusion you should do again projection radiography and you make sure whether there is a right position or not yeah you have enough potential to do everything more and more there is no border the quality control in the oh in the upstairs yeah so rule of immobilization the patient positioning and immobilization are the most important parts of RT I have written most important parts yeah the other part is also important goal of immobilization system is to limit patient motion and reduce the probability of major positioning errors with proper immobilization unwanted side effect immobilization charges molds cast headset headrest and other devices are constructed to reduce set of errors and patient movement during treatment so the role of immobilization a well constructed immobilization system can reduce time for daily patient setup this is actually also important not only place in position but when you have immobilization you can work very quick otherwise you have a connection with the patient you have collaboration with patient here you do not know just like a put it and radiate it so the two things are position accuracy and you can work very quick make the patient feed more secure and less apprehensive reduce the real ends of passion cooperation and alertness and it can help to stabilize the relationship between external skin marker and internal structure this is another important so there is a many many immobilization devices some old times and now the modern times and different head you there is a standard set maybe six six or seven then you can choose this and it fit always in the past passion for head and neck cancer were taped to the tablet across forehead as an tape is put here and a bite block was often used in order to tilt the neck in a reproducible manner in the mouth and so today's method for head and neck and brain tumors include a variety of a headrest max molds and frame system yeah this is everybody knows this aquaplast yeah this is actually a runner just like a working horse everywhere yeah the technician in the city room you have always a bath and the aquaplast every patient had this one when aquaplast the most common immobilization devices used to treat head and neck cancer the device is made from rigid plastic that become pliable when placed in warm water you can hold and mold in every every form of the body when it is wet it is placed over the patient body and conform to the contour of the treatment plan yeah you have up to the here in the shoulder you can put it yeah the shoulder retraction this also sometimes also in the older time some hospital have also seen this here you have some belt and both side the patient try also the shoulder go out of the neck so you have the both sides and bilateral field you can adjust otherwise the shoulder is there even in city you should also shoulder out of the field otherwise your handed neck you see the both sides of the head and it is you cutter you cut in the tps but in reality is not there so it should be actually out of the neck and treat the bilateral on the here is also possibility excuse me here is also possibility like this here you see here this is a coach and the patient is leaving and here and put it here on out of the neck and now we can place in from this side another side in the neck and head cancer this is the shoulder the retraction and in brain tumor yeah it is very extensive and not all hospital do the brain tumor like this tell you to actively like here they have some clinic very very good experience the heart man he has also very good experience in stereotype T they have done in Heidelberg there is a group they have their own such types of frame but in actually in commercial you can find these are both types of frame oh excuse me the both types of frame this is a Gil Thomas Cosman this is the standard in literature you can find also in some hospitals this is actually when the sitting is more than one then you have these types and when the single sitting than had been this type single sitting means you have radius surgery that's I put the dose one times and and then is a higher dose yeah you calculated through the biological parameter how many doses needed there is also biological formalism maybe 13 gray or the 10 gray and put it one times when this this this GTC it relocatable head ring in now invasive device that can be non-invasive yes this is non-invasive because you cannot operate three times maybe you have three sitting so it should be in non-invasive and can be repeatedly fixed so you need a fixed fixed coordinate and fixed position so you see the passion condition on the head ring yeah then on here and then both sides on here in the mouth so we have the three sitting is the same position then you have the still taxi and the other one is the single so here is actually the radio surgery and surgery both yeah then because in invasive procedures the patient is fitted with air bv system and then both bolted to the treatment table bolts are fitted and screwed into the patient's school to minimize any treatment during movement during duration so screw and fix everywhere sometimes they put external beam and sometimes you know the seats inside the passion go gold seats and it will stay inside the in the school so thorax and breast immobilization this is also very important so this immobilization is also very needed in MRT here this is a back look there are common immobilization system used in treated tumors in the chest cavity here the back look here so that's almost here equivalent and bashable to the unusable this can use again and again and this is a breast brought breast brought you know this one every hospital had this and here the arm so out of the breast position and yes then you have the head headset headset and then arm rest and slope to strengthen sternum in order to minimize the lung dose here these are roads and of course the leg rest is also important leg leg rest sometimes knee knee rest when everything is possible one of course in here is a base plate yeah the base plate and the indexing bar is also needed yeah on the base plate you fix the base plate in the coach and indexing bar otherwise it's moving so so this is also needed yeah pelvic immobilization this also important here there are two different crucial aspects of immobilization in pelvic region properly maintained patient outer contour during treatment with respect to isocenter other is related to variation of internal structure during daily treatments and these are all possible yeah the back lock belly boot hip fix as many many factory they are doing in in European level on then pelvic immobilization yeah once again here you see here the max put in the pelvic region a max from the patient mid thorax to upper thigh is made by stretching worm again the thermoplast over the patient and then secure that max to the pelvic boot by a looking system well what is this here pelvic immobilization once again this is back sack belly boot this is also a standard immobilization device every hospital belly boot yeah when you have belly boot allow the small boil to drop below the lateral fields to avoid sewer effects of yeah I have I have shown you a table for the dosy tolerance table and you have seen this is a very sensitive sensitive organ small boil so it should be out of out of the treatment yeah then you put out and then three fields on both sides and use of belly boot significant decrease the average volume of the mobile and would otherwise be within the lateral field during standard box techniques a box technique or a three field techniques here you see here the or like this yeah this is the coach this is the boat yeah these are whole body radiation yeah they have some these are old technology they have done have taken the old images from here and yeah sometimes movement is difficult to control example lung motion during the breathing determined motion and gate radiation yeah the gate radiation is actually in many hospital they are doing so it is also the standard or option in every TPS modality treatment planning modality low solution yeah I have given you the low solution but when the rush patient you cannot do that holds yeah they are all that time have reproducible bladder filling provided dietary advice yeah always the bladder is followed or empty and so and breath shallow and make patient feel compatible and secure it is possible low cost these are the differences