Norfolk, VA – September 5, 2024 – We sat down with Jennifer Mundine and Veronica Shilling, radiation therapists at St. Joseph Health Bryan Hospital at College Station, Texas. Jennifer and Veronica have 13 years, and more than 20 years of experience, respectively. Both RTTs use Orfit solutions every day. College Station is a diverse community, home to Texas A&M University and the “center hub” between Houston, Austin and Dallas. Therefore, St. Joseph Hospital is a convenient option for patients who don’t want to travel to Houston for treatments. The center has two linear accelerators with integrated imaging and they use Orfit solutions with both of them. One of the linacs, a Varian Edge with a high-definition MLC, is used for SBRT and SRS treatments, making it the system for which their new AIO SBRT 3.0 is most frequently used.
What types of cases and treatments are best suited to your Orfit Solution?
We have used it on many things, including our head-and-neck patients and lung and SBRT lung cases. In addition, we’ve used it for the abdomen, pancreas and kidney, and some breasts—treating the APBI breast and also for a couple of conventional breast treatments.
Can you describe your setups before and after implementing the Orfit solution?
We had the Orfit system for just the head-and-neck, so that wasn’t a huge transition for us when we acquired the AIO Solution, although now there are pegs on the new board. The pegs have especially helped with some of the head-and-neck patients, enabling patients to keep their shoulders down and out of the way, as opposed to having to use shoulder retractors with adjustable ropes to pull their shoulders down when we’re making the mask.
Here’s how we use the board for head-and-neck patients. The pegs help to get their shoulders down/retracted and out of the way. This shows the multiple uses we get out of the board, since we use it for head-and-neck, most breasts, lung, abdomen, and more as needed.
For the lungs, we were using the wing board and vacuum bags, and for breasts, we were using a breast board. For the abdomen, pancreas and kidneys, most of the time — if it was mid-abdomen, we were using upper and lower vacuum bags for stability. We’ve really liked the new board and the body thermoplastic that came with it — that’s been very helpful. The thermoplastic has been very beneficial for lung and abdominal treatments and has been setting up really nicely.
The Orfit system has been very beneficial for all of our setups—all head-and-neck, breast, lung and abdomen—for using the Orfit headrest, because it extends up to mid-skull. We know — based on the headrest and where the patient’s laying—whether the patient needs to scoot up or down.
This has been our biggest factor in our positive opinion of the boards and the setups that go with them. There’s no question where “in” and “out” are with the patient on the board.
This is what we use for most lungs and APBI breasts. Still using the headrest for a point of reference for where the patient lies on the board and the pegs for consistency with arm/hand placements for arm/shoulder rotation consistency.
Especially, too, when they put their arms up on the armrest—whether we’re using the steeper armrest or the smaller one—the arms are going to lay in the same spot, because the pegs are in the same spot. It’s also stable—the positioning will barely deviate from what you need. I believe we’re more consistent with our setups because of that.
Also, the images look really good. The shifts from the cone beam imaging were minimal to begin with—we already have our tolerances—but the shifts from there have been even more minimal. Especially when we’re treating SBRTs and the APBI breast, the shifts have been almost zero now.
For lungs, if we’re treating an upper lobe, such as with a lung lesion or with APBI breast treatments, we’ve gotten very consistent and stable results with arm positioning. By using the armrest and pegs, we’re not having issues with clavicles or humeral heads or how the arms are positioned—if they’re rolled one way or the other—depending on how patients are holding the pegs. With the pegs in the armrest, hand and arm placement will be consistent each time, such that when we’re treating something in the upper lobe of the lungs or in the breast, there is hardly any deviation. We’re getting a very consistent, reproducible setup every time.
Here’s another way we treat lungs/abdomens and anything that might need compression or to minimize respiratory motion. And the knee sponge also helps to position patients in and out on the board.
What do you like best about the Orfit solution?
The pegs and the armrest. When we were using vacuum bags, you could take only a limited number of setup pictures and try to get it exactly the same, but the arms are never 100% in the same spot. With the pegs and armrests, the Orfit solution helps so much more with that.
With the headrests, being able to identify the patient’s “in” and “out” on the board has helped so much in all of those that we treat—lungs, breasts and abdomen. When treating the abdomen, when we’re introducing the body thermoplastic, it’s helped a lot in terms of getting the patient straight and making sure, in-and-out-wise, exactly where we need to be, because the body thermoplastic masks are very form-fitting. I believe our simulation (SIM) therapist does a good job making them.
The headrest and pegs/t bar are employed to help with patient position with the headrest and t bar to provide consistency. The headrest helps with the patients in and out on the board. We also use the 10- degree wedge when we need to.
Can you share some tips and tricks for others who are getting started with the Orfit solution?
What we’ve started doing, is in SIM give a couple of straighteners, if we could—as far as midline on the chest area—to get them straight before we put on the body thermoplastic. Sometimes we have a little bit of a roll on patients, but we usually account for that on the cone beam CTs. We do get the straighteners on before we put the body thermoplast on and then, after we get them fairly straight with those, we put the body thermoplastic on and line up to where our marks are.
We try to level them before putting the body thermoplastic on, but that depends on how well they hold still in the timeframe of getting them straightened and leveled and then putting the body thermoplastic on. Some of them still want to wiggle when you get the body thermoplastic on, to help get in the groove, in the right spot. If we can get that done, it significantly minimizes our shifts and looks really good.
The first patient that we had hold onto the pegs at her side commented about the ease of being able to hold the pegs. It made her more relaxed, as opposed to holding the ring on our first Orfit board. She felt like that helped her feel a little more stable on the table.
Our physicians really like it too. They’ve been really pleased with it and happy with how the SBRT setups are going. One of the physicists—when we applied the very minimal shifts — said ‘Wow, this is really good. What did you all do today?’ We told him about the new system. He was really impressed with it.
[This interview has been edited and condensed.]
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