Surface contour scanning system - Improved accuracy and efficiency High level of integration Multiple applications

Laser-Camera Technology Optical triangulation

Sentinel, LS100 - Discrete installation - Technical evaluation at Karolinska, Stockholm - Clinical evaluation in Uppsala - First installation in Uppsala

Sentinel, LS200 - Attractive design - Simpler installation - Service friendly - Design ready Q1 2007 - Delivery Q2 2007

Sentinel system – SW and HW High level of user friendliness Connectivity Simplicity Efficiency

Connectivity - Network support

Sentinel – multiple applications Patient Positioning Motion Detection Respiratory Gating

Sentinel – Patient Positioning cPOSITIONING Improved accuracy Efficient workflow User friendly No additional markers No added radiation

User friendliness – Clinical mode

User friendliness – Advanced mode

Efficiency - Performance and Work flow Scan time is typically 3-5 seconds Surface matching takes typically 1 second Sub-millimetre accuracy

Sentinel – Motion Detection cMOTION Does not require active supervision Visualization Recording Alarm

cMOTION workflow cMOTION Integrated workflow with cPOSITITION or Stand-alone functionality Markerless solution Alternative to manual supervision (camera + monitor), userfriendly solution. cPOSITIONING cMOTION

Sentinel – Respiratory Gating cRESPIRATION Respiratory gating in the Sentinel system

Respiratory motion can affect the delivered dose distribution Background Respiratory motion can affect the delivered dose distribution Especially in the thorax/abdominal region Available solutions Increased margins More dose will be delivered to the surrounding healthy tissue Organs at risk must still be protected, which may be very difficult if they move near or into the desired target volume Gated treatment Dose delivery is synchronized with respiratory motion Potential for dose escalation, resulting in higher delivered dose to the tumor while healthy tissue is spared The correlation between internal and external (surrogate) motion must be known

Establishing correlation How can we establish the correlation between internal and external motion? 4D CT study Gated fluoroscopy (on a conventional simulator) End exhale End inhale 0% 100% Amplitude Gating window

Inter- and intrafractional variations Breathing patterns Inter- and intrafractional variations Changes in frequency and amplitude Thoraxic vs. abdominal breathing Irregularities (coughing, unexpected breath hold, patient movement) Solution Coached breathing/biofeedback Parallel monitoring of both thoraxic and abdominal respiratory motion Algorithms for detecting irregularities

The cRespiration workflow 3D CT study (gated) Gated CT study (retrospecive/ prospective) Gated treatment planning and delivery Gating parameters

Prospectively gated CT study CT room CT 3D CT study (gated) Establishing of gating parameters Real-time generation of gating signal Gating parameters Patient LS Respiratory signal

Retrospectively gated CT study CT room CT Sorting of CT data according to respiratory phase Selection of phases suitable for treatment 3D CT study (ungated) 3D CT study (gated) 4D CT study Patient Gating parameters LS Respiratory signal

Gated treatment planning and delivery Treatment room Treatment planning LINAC treatment delivery 3D CT study (gated) RT plan Gating enable (SW/HW) Real-time generation of gating signal Patient LS Respiratory signal Gating parameters

The cRespiration concept Simplicity No markers to be placed Integrated workflow through the whole process Confidence No additional dose Sub-millimeter accuracy, measured at the same locations every fraction without manual guidance Parallel monitoring of thoraxic and abdominal breathing Immediate detection of irregular breathing or patient motion Versatility Support for several modes of operation – deep inspiration/end expiration breath hold, as well as coached and free breathing Tight integration with CT and Linac equipment from major vendors

Milestones June 2008: Clinical validation activities begin In cooperation with the Academic hospital in Uppsala Philips Big Bore CT Elekta Precise Linac July 27-30 2008: AAPM in Houston, Texas First public demo of the cRespiration module Q4 2008: Commercial release to all markets 2009: Support for additional CT and Linac equipment, e.g. Varian, GE, Siemens

Sentinel - Integration in a RT clinic, c4D software System modules Patient alignment Full network support Motion detection (available Q2 2008) Gating functionality (available Q4 2008) Interfaces DICOM-RT interface for patient setup Interface to Elekta iCOM Interface to Varian 4D console Interface to Visir R&V Interface to Hexapod couch (Q2 2008)