Simulation

PREPARED BY: BINA ASHOK

Simulation:

 After diagnosis, the first step in designing and delivering radiation therapy to a
patient is called “simulation” meaning copy.
 Simulation is a process for determining the proper selection and orientation of
beams so that they properly overlap a target.
 Simulation requires the determination of patient dimensions for dose calculation
and the determination and/or creation of identifiable reference points to ensure
that beams are being aimed correctly.
Simulation:

 Simulation is radiotherapy field determination using a diagnostic X-ray machine

with similar physical and geometrical features to the actual teletherapy machine.
 The patient is immobilized before simulation and then the tumor is localized
either in a direct scopy X-ray machine or in serial CT slices.
 The simulation can be performed by CT, MRI, or rarely by PET–CT
Conventional Simulator:
Conventional Simulator:

 The simulation performed by a conventional simulator is a real-time simulation

procedure.
 Since it is done directly in the patient .
 However, the simulation performed by a CT or MRI is a virtual simulation since
the tumor is localized digitally.
Conventional Simulation Steps:

 Immobilization:
 The patient should be immobile during therapy.
 Movements cause changes in the treatment area and increase side effects, thus
affecting treatment success.
 The patient should be positioned in the most comfortable, easily reproducible way

 Various types of apparatus are used for immobilization. The most frequently used
apparatus is the thermoplastic mask for head and neck cancers.
 Such a mask should not only be tight; there should be no space between the
patient’s skin and the mask.
Conventional Simulation Steps:

 The mask should be checked during every setup procedure for tightness or
looseness (due to edema or weight loss)
 And should be remade if necessary.
Conventional Simulation Steps:

 Patient positioning:
 The patient’s treatment position should be recorded on both the patient’s chart
and the simulation film (e.g., supine, prone etc.)
 After the patient has been positioned on the couch, the desired SSD value
(usually 80–100 cm) is achieved by adjusting the couch height.
 The SSD is reduced by half the thickness of the patient.
 Finally, the irradiation field is determined according to the chosen technique
(fixed SSD or fixed SAD).
Conventional Simulation Steps:

 Imaging and tumor localization:

 The patient is placed on the simulator couch in the required position.
 Similar immobilization device is positioned accurately.
 The radiotherapy fields are determined and SSDs are calculated according to
patient thickness.
 Gantry angles, field sizes and collimator angles are arranged by the simulator
software
Field borders:
Conventional Simulation Steps:

 Any scar, palpable mass and drain site is marked with flexible wires; lead markers
 Oral or IV contrast material can be used if required.
 Therefore, the contrast material should be prescribed before simulation; first aid
equipment and drugs (e.g., adrenaline, atropine) should be available in the
simulator room.
Conventional Simulation Steps:

 Treatment fields and block regions are marked on the patient’s mask or skin after
determining the radiotherapy fields.
 Simulation radiographs are then taken, and protected areas are marked on this
film, which is sent to the block-cutting room.
 Blocks are then fabricated.
 The patient’s chart is sent to the physics room for dose calculations
Conventional Simulation Steps:

 If focalized blocks are used, the blocks can be checked on X-ray scopy by special
trays mounted on the simulator’s gantry.
 Minor errors can be corrected, but the blocks should be refabricated when there
are major errors.
 The daily dose fraction and the total dose are determined
 The patient’s chart is sent to the medical physics room for dose calculations after
all of these procedures.
 Schedules are arranged for the treatment machine.
CT Simulator:
CT Simulation:

 The mask and other required equipment are made on the day of CT simulation by
the radiotherapist for the patient who is to receive conformal radiotherapy
 The patient is sent to the nurse for an IV route before CT simulation if an IV
contrast material is to be used.
 Then the patient is positioned on the CT couch, and the similar device is fitted on
the CT couch if required.
CT Simulation:
CT Simulation / 3-D Conformal RT steps:

 The lasers are turned on and they are positioned at the midline according to the
region of interest.
 Reference points are determined by radio opaque markers located at the cross-
sections of the lasers
 Reference points are predetermined locations for each region of the body.
 There are three reference points:
 One is craniocaudal
 Others are on the right and left lateral sides
CT Simulation / 3-D Conformal RT steps:

 Contrast material is given intravenously by the nurse

 The region of interest (that for which serial CT slices are to be taken) is
determined by the radiation oncologist.
 The slice thickness is also determined.
 All of these data are transferred to the CT computer.
 After the region of interest has been verified on screen, serial slices are taken.
CT Simulation / 3-D Conformal RT steps:

 These slices are sent online to the treatment planning room via the network
(PACS)
 The patient should then rest for 20 min after CT to check for any possible adverse
reactions
 If no mask is used, particularly in the case of body simulations, reference points
should be permanently tattooed on, otherwise they will easily disappear.
CT Simulation Planning:

 A virtual digital simulation is performed after the CT slices have been transferred
to the network
 The radiation oncologist then performs contouring on the acquired CT slices.
 Radiation Oncologist then contours the GTV, CTV, PTV, and the organs at risk.
CT Simulation / 3-D Conformal RT steps:

 The slice with the reference points determined during CT simulation is recorded
as the reference slice.
 Contours are carefully checked and recorded, and the planning phase then begins.
 Delineation of the multileaf collimator (MLC) or the blocks is performed, and
critical structures are spared.
 Data on the energy, fraction number and dose, and the treatment machine are
entered into the planning computer
CT Planning:

The treatment planning system (TPS) starts its calculations and the final dose
distribution and dose–volume histograms are formed.
The doses for the target and the organs at risk are evaluated with the DVH
The final treatment plan should be verified by the radiation oncologist.
The final verified treatment plan is sent online to the treatment machine via the
network
Conventional vs Virtual Simulator:

 A conventional simulation requires the presence of patient for planning

 A conventional simulator is configured to resemble a linear accelerator and
consists of an x-ray tube and has fluoroscopic capabilities.
 X-ray imaging can be viewed in real-time to allow for the placement of the
isocenter and appropriate field borders.
 A conventional simulator can only take two-dimensional (2D) x-rays
Conventional vs Virtual Simulator:

 The x-rays usually display poor quality in that soft tissue contrast is minimal.
 A major disadvantage in using this type of simulator is the limitation to
distinguish between the different inhomogeneity corrections, such as bone and air
 This can present difficulties during treatment planning.
Conventional vs Virtual Simulator:

 One advantage of CT simulation is that the patient doesn’t have to be physically

present for the treatment planning process after the initial CT scan has been
obtained.
 The isocenter can be placed at a later time per the physician.
 The use of CT in treatment planning allows for 3D visualization of the patient’s
anatomy, which determines the best dose distribution to the target while sparing
surrounding normal tissue.
Conventional vs Virtual Simulator:

 Several critical structures can be contoured to delineate dose restraints and to

assist the therapists during imaging.
 Also from the scan, a digitally reconstructed radiograph (DRR) can be obtained
and used for verification on the treatment machine.
 A major disadvantage is that some CT simulators have a small aperture, causing
heavier patients to not be able to fit into the scanner and having to receive their
treatment elsewhere. A conventional simulator has no aperture or bore and is
open allowing for broader patients and immobilization devices to fit.