Reproducibility of patient setup in the seated treatment position: A novel treatment chair design

Abstract

Radiotherapy in a seated position may be indicated for patients who are unable to lie on the treatment couch for the duration of treatment, in scenarios where a seated treatment position provides superior anatomical positioning and dose distributions, or for a low-cost system designed using a fixed treatment beam and rotating seated patient. In this study, we report a novel treatment chair that was constructed to allow for three-dimensional imaging and treatment delivery while ensuring robust immobilization, providing reproducibility equivalent to that in the traditional supine position. Five patients undergoing radiation treatment for head-and-neck cancers were enrolled and were setup in the chair, with immobilization devices created, and then imaged with orthogonal X-rays in a scenario that mimicked radiation treatments (without treatment delivery). Six subregions of the acquired images were rigidly registered to evaluate intra- and interfraction displacement and chair construction. Displacements under conditions of simulated image guidance were acquired by first registering one subregion; the residual displacement of other subregions was then measured. Additionally, we administered a patient questionnaire to gain patient feedback and assess comparison to the supine position. Average inter- and intrafraction displacements of all subregions in the seated position were less than 2 and 3 mm, respectively. When image guidance was simulated, L-R and A-P interfraction displacements were reduced by an average of 1 mm, providing setup of comparable quality to supine setups. The enrolled patients, who had no indication for a seated treatment position, reported no preference in the seated or the supine position. The novel chair design provides acceptable inter- and intrafraction displacement, with reproducibility equivalent to that reported for patients in the supine position. Patient feedback will be incorporated in the refinement of the chair, facilitating treatment of head-and-neck cancer in patients who are unable to lie for the duration of treatment or for use in an economical fixed-beam setup.

Keywords: novel treatment positioning; patient positioning; upright treatment.

Figure 1

Treatment chair setup. For simulation, a flattop bench was used to mimic the treatment couch in the treatment vault. For image acquisition, the seat was securely fastened to the treatment couch. The setup is adjustable for patient size and comfort including adjustment of the seat depth (a), chest plate height (b), chest plate angle (c), face piece angle (d), and footrest height (e).

Figure 2

Patient setup for lateral image acquisition in the treatment vault, with kV imagers extended and couch positioned at 0°. The Vac‐Lok cushion was shaped so as to create armrests for patient comfort, the head mask was secured of the back of the patient's head.

Figure 3

Histogram‐normalized kilovoltage image of a representative patient, outlining the subregions selected on the lateral image (a) and PA image (b) for registration. C1C3 and C3C5, cervical vertebrae 1–3 and 3–5, respectively.

Figure 4

Face piece before and after the change implemented after feedback from the first two patients. Before the change, the chin‐and‐forehead pieces were covered with bolus material for comfort, and the inferior chin piece was arched for anatomical conformity.

Figure 5

The results of the patient questionnaire. Only questions separated by an average of 0.4 points (5‐point scale) or more are shown. The full questionnaire can be found in the supplemental materials. The questionnaire alternated the score assigned to a positive response. For example, a rating of 5 was assigned to answers of “I felt calm” and “Getting on the chair (couch) was difficult”. In this figure, all positive responses are correlated to ratings of 5, for clarity.