Immobilization Devices

Noreen Marwat
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• Immobilization device Immobilization device is a tool that is
used to ensure the position of the patient is stable. Patient is only
allowed to breathe normally.  To position target accurately.  To
minimise the dose to surrounding normal tissue as far as possible.
 Reduce the time in daily patient setup.  Makes the patient feel
more secure & comfortable during treatment. Why it is important?

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• 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

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• 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

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• Thermoplastic masks  thin sheets (usually 1.6mm to 3.2mm) of
solid or perforated plastic sheets bonded to a rigid frame  water
temperatures for perforated thermoplastic must be 165oF

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• 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.

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1. Stand behind your patient’s head, position the edge of the thermoplastic approximately 1.5 to 2” under the
patient’s chin.
2.The question mark technique  Begin by catching the patient’s chin approximately 1.5” inches into the
thermoplastic mesh. Gently pull the Uni- frame eight to ten inches in the superior direction, just above the patient’s
nose.
3.The question mark technique  Push the thermoplastic down diagonally toward your chest and onto the
baseplate.
4.The question mark technique  Pull the thermoplastic down and onto the black indexing pins of the baseplate.
Lock the Uni-frame to the baseplate with the quick- release locks.
5.The question mark technique  Reach under the mesh at the patient’s throat and “flair” the mesh out about 90o
away from the patient’s throat to create a smooth. Apply the three finger pinch at the bridge of the nose. Mold the
mesh against the nose and face to replicate the contours of the face for 30 to 45 seconds. Allow the mask to harden.

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1.Vac Lock Main:  To limit the patient movement  To reduce the probability of
positioning errors Incidental benefits:  Radiation in daily set up time  Radiation in
patient’s fear and worry  No need for patient to be awake, alert & co-operate 
Conversion into a rigid body
2.Characteristics of Vac-Lock  Easy to use  Easy to constructing the device  Patient
Comfort: Fully comfortable and relaxed position  All movements be constrained 
Device conforms to the patient’s external surface contours  The device be appropriate
to the particular patient (e.g. obese) and anatomy(e.g. abdomen) under treatment.
3.o Washable o Reusable

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1.Why Head Rests? Maxillary antrum tumors- -patient's head
positioned with chin hyper extended to include the superior extent of
the maxillary antrum in the anterior field without including the eye.
2.Why Head Rests? Pituitary or small brain tumors head positioned
with neck in extreme flexion Anterior beam can avoid the dose-
limiting structures such as the optic chiasm, the retina, and much of
the brain tissue

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Breast Board

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• Goal of Immobilization Devices 1. PRECISION/ACCURACY Limit
patient movement 2. REPRODUCIBILITY Reduce daily shifts 3.
PATIENT COMFORT Increase acceptance

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Immobilization

 “Incapable of movement”
• Radiotherapy is designed very precisely to treat exactly the right
area, so it is important to keep that part of the body as still as
possible during treatment
• Immobilization device is used to make sure the patient stays in
the treatment position during the course of treatment.

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Role of immobilization

• Patient positioning and immobilization are said to be the most

crucial parts of Radiotherapy Treatment. For accurate delivery of a
prescribed radiation dose to a target volume, while sparing
surrounding normal and critical structures. Without proper
immobilization ,the patient is at risk for improper treatment and
unwanted side effects. Immobilization such as
moulds,casts ,headrests and other devices are constructed to reduce
setup errors and patient movement during the treatment.
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• Although the primary goal of immobilization system is to limit
patient motion and reduce the probability of major positioning
errors.  A well constructed immobilizing system can reduce the time
of daily patient setup.  It can make the patient feel more secure and
less apprehensive.  It can reduce the reliance on patient co-
operation and alertness, and it can help to stabilize the relationship
between the external skin marks and internal structures.

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• DESIRABLE CHERECTERISTICS OF IMMOBILIZATION DEVICES.  Should be
transparent to allow visibility of beam light and optical distance indicator. 
Should be light weight, strong and durable.  Ease to use.  Ease of making
the device.  Comfort for the patient.  Minimal place requirement for the
storage.  Resistance of bending and stretching.  Minimal perturbation of
the beam so as not to produce any artifacts in the image acquisitions. 
Device be useable on simulator, CT/MRI and other treatment planning imaging
system.  Surface dose should not be altered.  Rigid & holds its shape over
time.
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• NEED FOR A POSITIONING DEVICES  Set up the patient in a
special position designed to improve the therapeutic ratio and
patient comfort.  Proximity of the target (PTV) to the
surrounding radiosensitive structures.  Optimal beam access is
limited by external anatomic features such as the extremities, a
large belly or a pendulous breast.

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• THERMOPLASTIC MOULD PREPARATION  The most common
immobilization device used to treat cancers is Thermoplastic. 
Available in different sizes and shapes.  It is rigid in room
temperature.  When it heated in water( for temperature 60 to 65
degree)the material softens and become malleable.  When it is
wet, it is placed over the patient body and conforms to the
contour of the treatment area

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• ADVANTAGES:- Thermoplastic provide great reproducibility in
daily treatment ,lightweight and easy to use.Additionally
modification can be made to mask if the patient experienced with
swelling or weight loss during the course of treatment.
DISADVANTAGES:- Windows cut can not be reused and when old it
becomes very soft when activated .

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• TYPES OF IMMOBILIZATION  Head & neck immobilization. 
Immobilization in Brain tumors.  Thorax and Breast
immobilization.  Pelvic and abdominal immobilization. 
Immobilization for the Body extremities.  SBRT solution with AIO
Board.

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• Head & neck immobilization.  Initial construction and selection
of proper immobilization for H&N cancer is one of the most
important parts of confirming proper treatment of the patient. 
Current methods for the H&N tumors include a variety of
masks ,molds, and frame systems.  In some instances, shoulder
Retractors are used to pull the shoulders out of the treatment
field for the neck

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• FIXATION BASE PLATE FOR H&N  The plate onto which the head
immobilization system is secured is referred to as a base plate. 
It is usually made of Perspex or carbon fiber.  It should be low z
material and should attenuate the radiation minimally when the
beam passes through it.

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• IMMOBILIZATION IN BRAIN For the General brain tumor and
whole brain cases the mostly common immobilization device is
the 3 clamp Thermoplastic orfit, Immobilization becomes more
complex for radiosurgery,Cyberknife and Gamma Knife procedure
because the requirements for positional and numerical accuracy
for the dose delivery are -+1mm

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• THORAX AND BREAST IMMOBILIZATION There are 3 common
immobilization Devices used when treating the tumors in the
chest cavity,  VACLOK.  BREAST BOARD.  2 CALMP OR 4 CLAMP
THORACIKC MOULD

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• Indexing Bar & Shoulder retraction  The two pin indexing bar is
designed for reproducible positioning and stable fixation of the base
plate.  The indexing bar can be placed at the desired indexing
indents the couch and can be locked.  Shoulder retraction in patients
with short neck or the patients where opp lateral fields are used to
treat the neck, The shoulders need to be retracted caudally to avoid
entrance and exit doses , and most probably reduce unwanted dose
passes through head of the humerus
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• IMPROVED IMMOBILIZATIO N TECHNIQUE SMALLER TREATMEN
T VOLUME HIGHLY PRECISED TREATMET HIGHER CURE RATE HI
GHER CONTROLLD DOSE

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 1.CONCLUSION  Throughout this introduction about the
immobilization device, it is hoped that the patient
understands the importance and its requirement in
radiotherapy treatment.  It also hoped that the patient
should prepare to give their best possible co-operation and
effort during this non painful device fabrication process to
give the best outcome.  Proper immobilization will minimize
the setup errors considerably in day to day patient setup.

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 Objective
• To limit movement of the patient
• To reduce the probability of positioning errors
Primary goal in treatment using radiation therapy
To deliver curative dose of radiation to the target
Minimizing the dose to surrounding normal tissue as far as
possible.

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Introduction
Any device that helps to establish and maintain the patient in a
fixed, well defined position from treatment to treatment over a
course of radiotherapy or prevent the patient from moving
during a single treatment session

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Incidental benefits

• Reduction in daily set up time

• Reduction in patient’s fear and worry
• No need for the patient to be awake, alert and co-operative.
• Conversion into a rigid body

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Immobilization
techniques
 
Primarily address the issue of reducing intra-treatment motion
improving reproducibility of patient position from day to day.
• Target volume margins
• Radiobiological rationale behind immobilization
• Use of 3D treatment planning and programs and new
treatment modalities

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Incidental benefits

• Reduction in daily set up time

• Reduction in patient’s fear and worry
• No need for the patient to be awake, alert and co-operative.
• Conversion into a rigid body

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Main consideration in
Patient positioning
Target volume to be treated
Structures to be spared
Treatment portal arrangement
General condition and comfort of patient

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 Desirable characteristics
• Ease of use
Click icon to add picture
• Ease of constructing the device
• Patient comfort : Fully supported in a comfortable and relaxed position
• Device should conform to the patient’s external surface contours
• The device should optimally position the patient so as to minimise the normal tissue complications
• It should not obstruct the path for beam
• Device should be usable on simulator, CT/MRI and other treatment planning imaging systems
• Surface dose should not be altered
• Adequate space for reference marks
• Rigid and hold its shape over time
• Re-usability
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 Aligning the patient for immobilization. Laser
Range 1.5 to 5 m
Line width < 0.5 mm at 3m
Line length >43 cm at 3m
 
 The indexing bar can be placed at the desired indexing indents Indexer
of the couch and it can be locked down by rotating the levers.
The base plate then can be positioned over the pins of the two
pin indexing bar
 Base Plate
• The plate onto which the head immobilization systems are
secured is usually referred to as a base plate. It’s material
should be strong, yet it should minimally attenuate the
radiation beam. Most base plates are acrylic and recently
carbon fiber base plates are hugely developed

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 Indexed Support
Provide means  to facilitate intertreatment set up reproducibilty.
Head cups,Head and Neck supports,Foam rubber wedges which
are carefully indexed by size,shape,elevation above the treatment
couch

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 Laser Subtitle
 
Chart

0
Category 1 Category 2 Category 3 Category 4

Series 1 Series 2 Series 3

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Table

Category 1 Category 2 Category 3 Category 4

Item 1 4.5 2.3 1.7 5

Item 2 3.2 5.1 4.4 3

Item 3 2.1 1.7 2.5 2.8

Item 4 4.5 2.2 1.7 7

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 Team

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 Slope of dose
response curve of many tumors is sufficiently large
i.e. little change in dose will significantly reduce tumor control
probability. 
y= % change in control/% change in dose y50~ 1.3 to 2
Strong corelation between local recurrence and inadequate
coverage of defined target volume within high dose region.
.

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High Precision treatment
technique

The development of new immobilization

methods and materials has made it
possible to immobilize almost any area of
body of a co-operative patient to 3mm,
allowing use of margins of no more than
5mm, except when target motion within
the patient is an issue.
Special techniques for head and neck
targets can yield positional accuracies of
1-2 mm or even less for invasive
immobilization

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 Thank you

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