by Elekta is an image guide robotic linear accelerator that combines high conformance beam shaping with exclusive 3D adaptive image guided radiation therapy (IGRT) / Volumetric Modulated Arc Therapy (VMAT). It is dedicated for intra-cranial and extra-cranial applications.

Decade have contributed to improved results and wider applications of radiosurgery. The role of radiosurgery has expended beyond its initial applications. Synergy-S is the ideal extra-cranial complement to Leksell Gamma Knife as combination of both creates stereotactic center of excellence.

It works like Gamma Knife having head frame, body fix imaging, image planning and special modality of self-imaging planar fluoroscopic event/ and 300-ray volume imaging. Its own table to confirm the target and then treatment either radiosurgery or radiotherapy over confirmed target. It has maximum accuracy in advanced stereotactic radiosurgery with reference to spinal applications like spinal metastasis. Its fluoroscopic image modality prior to treatment helps to minimize the risk of set-up error by Identifying critical structured during treatment, thus compensating organ motion like heart, lungs, larynx and abdominal structures.

Having Synergy-S multi leaves (micro-macro) collimator system work automatically with powerful software driven 2D & 3D image-guided accuracy enables Oncologists to apply SRS/SBRT effectively for small field and large field lesions.

Indications:

Intracranial Indications: Large tumors, tumors closely lying near to critical organs, tumors embedded into the organ at risk or microscopic disease,etc.

Benign : Meningioma, Pituitary Adenoma, Acoustic Schawanoma, AVM, Cavernoma, Functional disorders, Psychiatric disorders, etc.

Malignant: Brain Metastases, Recurrent Gliomas, etc.

Extra Cranial Indications: SBRT is now a standard procedure for many of the extra-cranial regions including: Spine, Lung, Liver, Prostate, and Oligometases( New concept with cure or radical treatment with SBRT/SRS in stage –IV Cancers.

Volumetric Modulated Arc Therapy (VMAT)

It was introduced in 2007 and was described as a novel radiation technique that has continuous modulation of MLCs (field shaping), along with the dose rate and gantry speed rotation utilized to deliver highly conformal dose distributions simultaneously, in a minimal time period with reasonable MUs to be delivered. Otto did a remarkable job by developing the treatment planning algorithm for single arc VMAT. VMAT carries an advantage over IMAT in terms of greater degree of freedom with above factors that increase the capability of beam intensity modulation. Teoh et al. published comprehensive review article on VMAT in 2011. VMAT is becoming an increasingly utilized radiation technique. It proved as a novel and emerging technology with freedom of selection of number of arcs and some other features making it more efficient and faster in terms of treatment time and MUs delivery, its ability to spread low dose to a wide area of normal tissue, ability to deliver complex treatments with coplanar or non-coplanar single or multiple arcs make it a unique technology. The risk of secondary malignancy in VMAT should be lower as VMAT generally uses fewer monitor units (MU) compared with conventional fixed field IMRT. Macchia et al, published a detailed review of VMAT and its clinical use for various body sites in 2017, this study described that VMAT has been used mostly for brain tumors, head & neck, thoracic cancers, GU cancers, GI cancers and SBRT for oligometastasis.

VMAT-SIB is a popular technique that allows treatment of several volumes with different dose prescriptions called simultaneous integrated boost (SIB) is conveniently executed with VMAT technology that results into delivery of high biological effective doses to the target and reduction of the dose to the surrounding normal tissues and improvement of the toxicity. Macchia et al, concluded that the clinical use of VMAT is less documented, but VMAT-SIB and VMAT-SBRT is an effective and safe technique for various cancers of the body. More clinical data will emerge by the time as the numbers of patients are increasing across the world.

VMAT-SRS is described by Hanna et al.9, as a reliable therapeutic modality of SRS based upon the existing dosimetric research on its safety and benefits particularly in multiple brain metastases. They considered VMAT similar to the “non-VMAT” approach in terms of treatment plan acceptability (conformity and heterogeneity), treating multiple lesions and offering frameless radiosurgery treatments under image guidance.

In 2008, Gamma knife & Linac based Stereotactic Radiosurgery/Radiotherapy setup was established at Neurospinal & Cancer Care Institute (NCCI) Karachi by Prof. A. Sattar M Hashim (Neurosurgeon). So, our group emerged as a pioneer of stereotactic radiosurgery (SRS) /stereotactic body radiotherapy (SBRT) in Pakistan. Initially we have been using various forms of IMRT: fixed beam, step and shoot, forward and inverse IMRT from 2008 till 2013. Later we were able to have a license to use VMAT technology. Since 2014 we are using VMAT, VMAT-SIB and VMAT-SRS/SBRT techniques on regular basis.

SYNERGY-S / SYNERGY-AGILITY

Along with Synergy-S, Another New Linear Accelerator “SYNERGY-AGILITY has already been Installed at NCCI to carry out Stereotactic Body Radiotherapy.

REVOLUTIONARY ACCURACY IN TREATMENT DELIVERY

Synergy-S is the only fully digitally controlled linear accelerator available for extra-craniaI stereotactic applications. It is the first system of its kind with 3D imaging of the target area at the point of treatment delivery. We call this 4D Adaptive IGRT – high-resolution imaging in three dimensions of physical space and the tooth dimension of time.

Dose control and high conformance

Synergy-S delivers high dose rates with exceptionally fine control and precision. The system enhances avoidance of critical structures during beam delivery with its innovative 3D imaging technology. This technology allows beam adaptation for individual treatment sessions to achieve high precision and excellent target conformance, plus, digital controls which maximize the accuracy of dose delivery without compromise.

Synergy- S offers with stable dose/emu calibration and the most accurate IMRT/VMAT delivery available.

Multi-modality energy flexibility

Synergy-S offers an unprecedented selection of therapeutically effective X-ray beams. With the flexibility to select a higher energy X-ray beam than AMA, physicians can optimize the dose distribution by choosing energy appropriate to the site and depth of the lesion.

Intelligent beam shaping

Agility is the next generation, high resolution beam shaping solution from Elekta. Built on a strong understanding of the factors that are critical to patient plan optimization and treatment delivery, Agility is designed to meet the needs of modern radiotherapy facilities. Agility offers excellent clinical flexibility and efficiency, while ensuring that patient safety and comfort remain a priority.

Rapid leaf

40 x 40 cm field size.One hundred and sixty Inter digitating leaves with 5 mm width at isocenter. Integrated digital control of leaves and dynamic leaf guides. Accurate leaf positioning with Rubicon optical technology. Rapid leaf speed. Extremely low leaf transmission (<0.5%). 45 cm isocentric clearance.

Shorter treatment times

The high leaf and diaphragm speed provided by Agility increases the speed of delivery and allows higher dose rates to be used for more effective modulation. Not only does this help to improve plan quality, but it also shortens treatment times considerably. Shorter treatment times mean that more patients can be treated in a working day.

Multifunctional

Agility is ideal for the treatment of large or small field shapes and for the delivery of static or dynamic treatment plans for conventional or stereotactic techniques. You can even deliver off-center, non-coplanar treatment plans.Agility offers high resolution beam shaping, including interdigitation, across the 40 x 40 cm field size. Synchronized intelligent dynamic leaf guide movement and individual leaf movement achieves enhanced leaf speed and removes the need for a split field for seamless delivery of each prescribed beam shape. These features combined with a market leading 45 cm iso-centric clearance ensure that your linac is truly multi-functional.

Rubicon optical positioning system

The robust and reliable “Rubicon optical positioning system” provides valuable real-time assurance of accurate leaf positioning. Agility’s Rubicon optical technology offers advanced real-time leaf monitoring and positioning. Ultraviolet light from an LED source produces infrared fluorescence when it falls on the ruby tips of the multileaf collimator leaves. This infrared fluorescence, detected by an infrared camera, is used to reliably monitor and accurately position the leaves and can be viewed in real-time on the linear accelerators display screen.

Inherent safety supervisor

In addition, Integrity™, the fully integrated Elekta digital control system, provides: Continuous monitoring and control throughout treatment for confidence in beam shaping and treatment delivery. Verification that the field being delivered matches the prescribed treatment parameters. Inherent safety features that supervise and check that all systems are operating correctly.

Lowest Leaf transmission

The transmission and penumbra measurements indicate a significant improvement on the published data for comparable equipment. In particular, leaf transmission is extremely low, less than 0.5%. Cosgrove et al (2009). Agility has exceptionally low leaf transmission at less than 0.5% across the entire field1. This is important for a number of reasons:

It reduces unwanted dose to organs at risk and healthy tissue. Low integral dose reduces the risk of inducing secondary tumors. It reduces off axis dose when performing off-axis beam shaping. It improves treatment plan quality.

High-resolution beam-shaping

Synergy S and Synergy-Agility includes an integrated multi leaf collimator with a generous 40cm x 40 cm field size. The field comprises 160 individually controlled leaves. Physicists can create a range of finely shaped, high-resolution fields within one field simultaneously. This contributes to patient safety and improved conformal avoidance of critical structures.

Beam angle flexibility

Synergy S and Synergy-Agility features a small diameter 62cm treatment head which in combination with the best isocenter clearance, maximizes clearance around the patient and contributes to the wide variety of treatment approaches possible, including non-coplanar treatments. This enables Synergy S and Synergy-Agility to deliver radiation from angles impossible to replicate with other systems. Synergy S and Synergy-Agility can also radiate from underneath the couch for spinal applications, with the patient in the supine position.

Complete quality assurance

Integrated quality assurance (QA) tools ‘whole a kV/MV phantom to maintain excellent image quality and automated multi-leaf calibration software for the beam modulator that utilizes iView-GT MV images. This turnkey QA package enables the physics team to maximize efficiency and maintain the highest levels of device precision.

ABSOLUTE ACCURACY IN PLANNING- MONACO 5.11 – TPS

Synergy S and Synergy-Agility integrates a suite of sophisticated software tools to provide unprecedented target accuracy and help improve patient outcomes. Monaco-5.11- Treatment Planning System ( TPS) reduces complexity and enables Physicists to create high-precision plans that are easy to deliver and verify. It supports all linear accelerator clinical techniques.

Modern TPS-Monaco-5.11 is placed with the following techniques availability: 3D conformal radiation therapy, IMRT, VMAT, Stereotactic MLC and Cones.

Extreme flexibility

Planners can run multiple plans simultaneously, switching instantaneously from one patient to another without having to save work and exit. Planners can also switch instantly from contouring to planning, from 2D to 3D, or many other Precise PLAN mode, this significantly improves planning efficiency. Workflow can be further improved by using Windows remote access planning (WRAP.) which supports client workstations away from the dosimetry room servers.

Accurate imaging

With Monaco-5.11- TPS, MR and CT, PET-CT images can easily be included in the treatment plan. The software transfers images directly from scanners, ensuring seamless integration and instant access to critical information. Planners can also easily import contoured images from virtual simulation systems.

Fast contouring

Monaco-5.11- TPS supports fast structure contouring via manual or automatic outlining. Bony anatomy, organs and other critical structures can be found automatically. For manually entered contours, copy and paste and interpolation tools can be used to copy structures onto neighboring slices for rapid contouring without redrawing. Ultimately, reducing the true spent planning.

Customized evaluation

Monaco-5.11- TPS allows customization of planning workspace to match the clinic’s preferences, so that physicians can see the data in the preferred way. Multiple screens display any combination of axial, sagittal, coronal and oblique CT/MR images and can include both beams-eye-view (BEV) images and digitally reconstructed radiographs (DRRs). On every selected screen, Monaco-5.11- TPS calculated close rapidly for easy review and rapid evaluation.

 

3D IMAGING-VOLUME VIEW

Volume View software enables 3D volume imaging of soft tissue critical structures at the time of treatment and in the treatment position. Imaging can be repeated as often as necessary throughout the course of treatment. This allows margins to be reduced and uncertainties in target dimension, location and movement to be accommodated, minimizing the side effects of radiation, and allowing neurosurgeons to prescribe very high doses with confidence. Volume View will revolutionize the localization of tumor and critical organs during treatment delivery. It captures a complete 3D volume of the area of interest in a single acquisition, enabling rapid registration against the CT treatment plan image. Volume View ensures excellent spatial resolution and displays slices of anatomy in any direction with equally high resolution which is ideal for positional registration.

XVI – IGRT Verification

2-D, 3-D, 4D soft tissue imaging during treatment delivery. Verify anatomical position and motion during treatment. Increased confidence for dose escalation.

Record & VerifyXVI – IGRT Verification/h5>

MOSAIQ is record & verify system. From Demographic information to treatment planning information, various department records and QA is available in this system. An Excellent tool for enhanced workflows for improvement of further clinical efficiency.

2D monitoring – Motion View & Planar View

Motion View & Planar View imaging software, clinicians can monitor the effects of patient motion during treatment. Motion View is a unique 25 sequence mode that enables real-time viewing of anatomy while the patient is in the treatment position. Planar View offers exceptionally fast low-dose snapshots of the patient in the treatment position.

Beams-eye-view imaging – iView GT mega

The iView-GT megavoltage portal imaging system provides a beams-eye-view of the treatment delivery. Enabling a unique view of what is being treated in real time.

 

PATIENT IMMOBILIZATION SOLUTIONS

Comfortable body immobilization solutions available as follows:

Stereotactic Body Frame

Stereotactic Body Frame enables clinicians to localize turners precisely in a 3D stereotactic coordinate system, increasing the accuracy of radiation delivery. It allows high dose treatments with minimal exposure to surrounding healthy tissues, establishing a reliable basis for hypofraction. With the Stereotactic Body Frame, Radiation Oncologist/Physics can reproducibly localize isocentric target coordinates during planning and treatment. The system includes built-in reference indicators (fuducial markers) for CT and MR determination of target coordinates.

Body FIX RT

Body FIX- RT immobilizes firmly and gently throughout imaging, simulation and treatment. It is ideal for use with Synergy-S, In conjunction with Hexa POD Couch and minimizes involuntary patient movement during imaging and Radiotherapy. Body FIX- RT is composed entirely of radio-translucent materials compatible with CT, MR, PET, SPECT and ultrasound modalities.

Motion Management System

“Symmetry”Motion Management System assures the physiologic body motion control during treatment.

4-D CT and 4-D Treatment Planning compliments the motion control during Stereotactic radiosurgery treatment. Easy and Friendly software, keeps patient’s breathing comfortable during treatment.