Index of content:
Volume 41, Issue 2, February 2014
The authors present initial progress toward a clinically compatible x-ray phase contrastCT system, using glancing-angle x-raygrating interferometry to provide high contrast soft tissueimages at estimated by computer simulation dose levels comparable to conventional absorption based CT.Methods:
DPC-CT scans of a joint phantom and of soft tissues were performed in order to answer several important questions from a clinical setup point of view. A comparison between high and low fringe visibility systems is presented. The standard phase stepping method was compared with sliding window interlaced scanning. Using estimated dose values obtained with a Monte-Carlo code the authors studied the dependence of the phase imagecontrast on exposure time and dose.Results:
Using a glancing angle interferometer at high x-ray energy (∼45 keV mean value) in combination with a conventional x-ray tube the authors achieved fringe visibility values of nearly 50%, never reported before. High fringe visibility is shown to be an indispensable parameter for a potential clinical scanner. Sliding window interlaced scanning proved to have higher SNRs and CNRs in a region of interest and to also be a crucial part of a low dose CT system. DPC-CT images of a soft tissue phantom at exposures in the range typical for absorption based CT of musculoskeletal extremities were obtained. Assuming a human knee as the CT target, good soft tissue phase contrast could be obtained at an estimated absorbed dose level around 8 mGy, similar to conventional CT.Conclusions:
DPC-CT with glancing-angle interferometers provides improved soft tissuecontrast over absorption CT even at clinically compatible dose levels (estimated by a Monte-Carlo computer simulation). Further steps in image processing, data reconstruction, and spectral matching could make the technique fully clinically compatible. Nevertheless, due to its increased scan time and complexity the technique should be thought of not as replacing, but as complimentary to conventional CT, to be used in specific applications.
41(2014); http://dx.doi.org/10.1118/1.4824437View Description Hide Description
- MEDICAL PHYSICS LETTER
41(2014); http://dx.doi.org/10.1118/1.4861820View Description Hide DescriptionPurpose:
Currently, no 3D or 4D volumetric x-ray imaging techniques are available for intrafraction verification of target position during actual treatment delivery or in-between treatment beams, which is critical for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) treatments. This study aims to develop a limited-angle intrafraction verification (LIVE) system to use prior information, deformation models, and limited angle kV-MV projections to verify target position intrafractionally.Methods:
The LIVE system acquires limited-angle kV projections simultaneously during arc treatment delivery or in-between static 3D/IMRT treatment beams as the gantry moves from one beam to the next. Orthogonal limited-angle MV projections are acquired from the beam's eye view (BEV) exit fluence of arc treatment beam or in-between static beams to provide additional anatomical information. MV projections are converted to kV projections using a linear conversion function. Patient prior planning CT at one phase is used as the prior information, and the on-board patient volume is considered as a deformation of the prior images. The deformation field is solved using the data fidelity constraint, a breathing motion model extracted from the planning 4D-CT based on principal component analysis (PCA) and a free-form deformation (FD) model. LIVE was evaluated using a 4D digital extended cardiac torso phantom (XCAT) and a CIRS 008A dynamic thoracic phantom. In the XCAT study, patient breathing pattern and tumor size changes were simulated from CT to treatment position. In the CIRS phantom study, the artificial target in the lung region experienced both size change and position shift from CT to treatment position. Varian Truebeam research mode was used to acquire kV and MV projections simultaneously during the delivery of a dynamic conformal arc plan. The reconstruction accuracy was evaluated by calculating the 3D volume percentage difference (VPD) and the center of mass (COM) difference of the tumor in the true on-board images and reconstructed images.Results:
In both simulation and phantom studies, LIVE achieved substantially better reconstruction accuracy than reconstruction using PCA or FD deformation model alone. In the XCAT study, the average VPD and COM differences among different patient scenarios for LIVE system using orthogonal 30° scan angles were 4.3% and 0.3 mm when using kV+BEV MV. Reducing scan angle to 15° increased the average VPD and COM differences to 15.1% and 1.7 mm. In the CIRS phantom study, the VPD and COM differences for the LIVE system using orthogonal 30° scan angles were 6.4% and 1.4 mm. Reducing scan angle to 15° increased the VPD and COM differences to 51.9% and 3.8 mm.Conclusions:
The LIVE system has the potential to substantially improve intrafraction target localization accuracy by providing volumetric verification of tumor position simultaneously during arc treatment delivery or in-between static treatment beams. With this improvement, LIVE opens up a new avenue for margin reduction and dose escalation in both fractionated treatments and SRS and SBRT treatments.
41(2014); http://dx.doi.org/10.1118/1.4862509View Description Hide DescriptionPurpose:
We report on the clinical process, quality assurance, and geometric and dosimetric results of the first clinical implementation of electromagnetic transponder-guided MLC tracking which occurred on 28 November 2013 at the Northern Sydney Cancer Centre.Methods:
An electromagnetic transponder-based positioning system (Calypso) was modified to send the target position output to in-house-developed MLC tracking code, which adjusts the leaf positions to optimally align the treatment beam with the real-time target position. Clinical process and quality assurance procedures were developed and performed. The first clinical implementation of electromagnetic transponder-guided MLC tracking was for a prostate cancer patient being treated with dual-arc VMAT (RapidArc). For the first fraction of the first patient treatment of electromagnetic transponder-guided MLC tracking we recorded the in-room time and transponder positions, and performed dose reconstruction to estimate the delivered dose and also the dose received had MLC tracking not been used.Results:
The total in-room time was 21 min with 2 min of beam delivery. No additional time was needed for MLC tracking and there were no beam holds. The average prostate position from the initial setup was 1.2 mm, mostly an anterior shift. Dose reconstruction analysis of the delivered dose with MLC tracking showed similar isodose and target dose volume histograms to the planned treatment and a 4.6% increase in the fractional rectal V60. Dose reconstruction without motion compensation showed a 30% increase in the fractional rectal V60 from that planned, even for the small motion.Conclusions:
The real-time beam-target correction method, electromagnetic transponder-guided MLC tracking, has been translated to the clinic. This achievement represents a milestone in improving geometric and dosimetric accuracy, and by inference treatment outcomes, in cancer radiotherapy.
- RADIATION THERAPY PHYSICS
41(2014); http://dx.doi.org/10.1118/1.4859335View Description Hide DescriptionPurpose:
To investigate the potential of low-Z/low-MV (low-Z) linac targets for gold nanoparticle radiotherapy (GNPT) and to determine the microscopic dose enhancement ratio (DER) due to GNP for the alternative beamlines. In addition, to evaluate the degradation of dose enhancement arising from the increased attenuation of x rays and larger skin dose in water for the low-MV beams compared to the standard linac.Methods:
Monte Carlo simulations were used to compute dose and DER for various flattening-filter-free beams (2.5, 4, 6.5 MV). Target materials were beryllium, diamond, and tungsten-copper high-Z target. Target thicknesses were selected based on 20%, 60%, 70%, and 80% of the continuous slowing down approximation electron ranges for a given target material and energy. Evaluation of the microscopic DER was carried out for 100 nm GNP including the degradation factors due to beam attenuation.Results:
The greatest increase in DER compared to the standard 6.5 MV linac was for a 2.5 MV Be-target (factor of ∼2). Skin dose ranged from ∼10% (Be, 6.5 MV-80%) to ∼85% (Be, 2.5 MV-20%) depending on the target case. Attenuation of 2.5 MV beams at 22 cm was higher by ∼75% compared with the standard beam. Taking into account the attenuation at 22 cm depth, the effective dose enhancement was up to ∼60% above the DER of the high-Z target. For these cases the effective DER ranged between ∼1.6 and 6 compared with the standard linac.Conclusions:
Low-Z (2.5 MV) GNPT is possible even after accounting for greater beam attenuation for deep-seated tumors (22 cm) and the increased skin dose. Further, it can lead to significant sparing of normal tissue while simultaneously escalating the dose in the tumor cells.
A modern Monte Carlo investigation of the TG-43 dosimetry parameters for an 125I seed already having AAPM consensus data41(2014); http://dx.doi.org/10.1118/1.4860135View Description Hide DescriptionPurpose:
To investigate potential causes for differences in TG-43 brachytherapy dosimetry parameters in the existent literature for the model IAI-125A125I seed and to propose new standard dosimetry parameters.Methods:
The MCNP5 code was used for Monte Carlo (MC) simulations. Sensitivity of dose distributions, and subsequently TG-43 dosimetry parameters, was explored to reproduce historical methods upon which American Association of Physicists in Medicine (AAPM) consensus data are based. Twelve simulation conditions varying125I coating thickness, coating mass density, photon interaction cross-section library, and photon emission spectrum were examined.Results:
Varying125I coating thickness, coating mass density, photon cross-section library, and photon emission spectrum for the model IAI-125A seed changed the dose-rate constant by up to 0.9%, about 1%, about 3%, and 3%, respectively, in comparison to the proposed standard value of 0.922 cGy h−1 U−1. The dose-rate constant values by Solberg et al. [“Dosimetric parameters of three new solid core 125I brachytherapy sources,” J. Appl. Clin. Med. Phys.3, 119–134 (2002)], Meigooni et al. [“Experimental and theoretical determination of dosimetric characteristics of IsoAid ADVANTAGE™ 125I brachytherapy source,” Med. Phys.29, 2152–2158 (2002)], and Taylor and Rogers [“An EGSnrc Monte Carlo-calculated database of TG-43 parameters,” Med. Phys.35, 4228–4241 (2008)] for the model IAI-125A seed and Kennedy et al. [“Experimental and Monte Carlo determination of the TG-43 dosimetric parameters for the model 9011 THINSeed™ brachytherapy source,” Med. Phys.37, 1681–1688 (2010)] for the model 6711 seed were +4.3% (0.962 cGy h−1 U−1), +6.2% (0.98 cGy h−1 U−1), +0.3% (0.925 cGy h−1 U−1), and −0.2% (0.921 cGy h−1 U−1), respectively, in comparison to the proposed standard value. Differences in the radial dose functions between the current study and both Solberg et al. and Meigooni et al. were <10% for r ≤ 5 cm, and increased for r > 5 cm with a maximum difference of 29% at r = 9 cm. In comparison to Taylor and Rogers, these differences were lower (maximum of 2% at r = 9 cm). For the similarly designed model 6711 125I seed, differences did not exceed 0.5% for 0.5 ≤ r ≤ 10 cm. Radial dose function values varied by 1% as coating thickness and coating density were changed. Varying the cross-section library and source spectrum altered the radial dose function by 25% and 12%, respectively, but these differences occurred at r = 10 cm where the dose rates were very low. The 2D anisotropy function results were most similar to those of Solberg et al. and most different to those of Meigooni et al. The observed order of simulation condition variables from most to least important for influencing the 2D anisotropy function was spectrum, coating thickness, coating density, and cross-section library.Conclusions:
Several MC radiation transport codes are available for calculation of the TG-43 dosimetry parameters for brachytherapy seeds. The physics models in these codes and their related cross-section libraries have been updated and improved since publication of the 2007 AAPM TG-43U1S1 report. Results using modern data indicated statistically significant differences in these dosimetry parameters in comparison to data recommended in the TG-43U1S1 report. Therefore, it seems that professional societies such as the AAPM should consider reevaluating the consensus data for this and others seeds and establishing a process of regular evaluations in which consensus data are based upon methods that remain state-of-the-art.
41(2014); http://dx.doi.org/10.1118/1.4860175View Description Hide DescriptionPurpose:
In skin high-dose-rate (HDR) brachytherapy, sources are located outside, in contact with, or implanted at some depth below the skin surface. Most treatment planning systems use the TG-43 formalism, which is based on single-source dose superposition within an infinite water medium without accounting for the true geometry in which conditions for scattered radiation are altered by the presence of air. The purpose of this study is to evaluate the dosimetric limitations of the TG-43 formalism in HDR skin brachytherapy and the potential clinical impact.Methods:
Dose rate distributions of typical configurations used in skin brachytherapy were obtained: a 5 cm × 5 cm superficial mould; a source inside a catheter located at the skin surface with and without backscatter bolus; and a typical interstitial implant consisting of an HDR source in a catheter located at a depth of 0.5 cm. Commercially available HDR60Co and 192 Ir sources and a hypothetical 169Yb source were considered. The Geant4 Monte Carlo radiation transport code was used to estimate dose rate distributions for the configurations considered. These results were then compared to those obtained with the TG-43 dose calculation formalism. In particular, the influence of adding bolus material over the implant was studied.Results:
For a 5 cm × 5 cm192Ir superficial mould and 0.5 cm prescription depth, dose differences in comparison to the TG-43 method were about −3%. When the source was positioned at the skin surface, dose differences were smaller than −1% for 60Co and 192Ir, yet −3% for 169Yb. For the interstitial implant, dose differences at the skin surface were −7% for 60Co, −0.6% for 192Ir, and −2.5% for 169Yb.Conclusions:
This study indicates the following: (i) for the superficial mould, no bolus is needed; (ii) when the source is in contact with the skin surface, no bolus is needed for either 60Co and 192Ir. For lower energy radionuclides like 169Yb, bolus may be needed; and (iii) for the interstitial case, at least a 0.1 cm bolus is advised for 60Co to avoid underdosing superficial target layers. For 192Ir and 169Yb, no bolus is needed. For those cases where no bolus is needed, its use might be detrimental as the lack of radiation scatter may be beneficial to the patient, although the 2% tolerance for dose calculation accuracy recommended in the AAPM TG-56 report is not fulfilled.
Offline multiple adaptive planning strategy for concurrent irradiation of the prostate and pelvic lymph nodes41(2014); http://dx.doi.org/10.1118/1.4860663View Description Hide DescriptionPurpose:
Concurrent irradiation of the prostate and pelvic lymph nodes (PLNs) can be challenging due to the independent motion of the two target volumes. To address this challenge, the authors have proposed a strategy referred to as Multiple Adaptive Planning (MAP). To minimize the number of MAP plans, the authors’ previous work only considered the prostate motion in one major direction. After analyzing the pattern of the prostate motion, the authors investigated a practical number of intensity-modulated radiotherapy (IMRT) plans needed to accommodate the prostate motion in two major directions simultaneously.Methods:
Six patients, who received concurrent irradiation of the prostate and PLNs, were selected for this study. Nine MAP-IMRT plans were created for each patient with nine prostate contours that represented the prostate at nine locations with respect to the PLNs, including the original prostate contour and eight contours shifted either 5 mm in a single anterior-posterior (A-P), or superior-inferior (S-I) direction, or 5 mm in both A-P and S-I directions simultaneously. From archived megavoltage cone beam CT (MV-CBCT) and a dual imaging registration, 17 MV-CBCTs from 33 available MV-CBCT from these patients showed large prostate displacements (>3 mm in any direction) with respect to the pelvic bones. For each of these 17 fractions, one of nine MAP-IMRT plans was retrospectively selected and applied to the MV-CBCT for dose calculation. For comparison, a simulated isocenter-shifting plan and a reoptimized plan were also created for each of these 17 fractions. The doses to 95% (D95) of the prostate and PLNs, and the doses to 5% (D5) of the rectum and bladder were calculated and analyzed.Results:
For the prostate, D95 > 97% of the prescription dose was observed in 16, 16, and 17 of 17 fractions for the MAP, isocenter-shifted, and reoptimized plans, respectively. For PLNs, D95 > 97% of the prescription doses was observed in 10, 3, and 17 of 17 fractions for the three types of verification plans, respectively. The D5 (mean ± SD) of the rectum was 45.78 ± 5.75, 45.44 ± 4.64, and 44.64 ± 2.71 Gy, and the D5 (mean ± SD) of the bladder was 45.18 ± 2.70, 46.91 ± 3.04, and 45.67 ± 3.61 Gy for three types of verification plans, respectively.Conclusions:
The MAP strategy with nine IMRT plans to accommodate the prostate motions in two major directions achieved good dose coverage to the prostate and PLNs. The MAP approach can be immediately used in clinical practice without requiring extra hardware and software.
41(2014); http://dx.doi.org/10.1118/1.4859355View Description Hide DescriptionPurpose:
To develop mathematical models to predict the evolution of tumor geometry in cervical cancer undergoing radiation therapy.Methods:
The authors develop two mathematical models to estimate tumor geometry change: a Markov model and an isomorphic shrinkage model. The Markov model describes tumor evolution by investigating the change in state (either tumor or nontumor) of voxels on the tumor surface. It assumes that the evolution follows a Markov process. Transition probabilities are obtained using maximum likelihood estimation and depend on the states of neighboring voxels. The isomorphic shrinkage model describes tumor shrinkage or growth in terms of layers of voxels on the tumor surface, instead of modeling individual voxels. The two proposed models were applied to data from 29 cervical cancer patients treated at Princess Margaret Cancer Centre and then compared to a constant volume approach. Model performance was measured using sensitivity and specificity.Results:
The Markov model outperformed both the isomorphic shrinkage and constant volume models in terms of the trade-off between sensitivity (target coverage) and specificity (normal tissue sparing). Generally, the Markov model achieved a few percentage points in improvement in either sensitivity or specificity compared to the other models. The isomorphic shrinkage model was comparable to the Markov approach under certain parameter settings. Convex tumor shapes were easier to predict.Conclusions:
By modeling tumor geometry change at the voxel level using a probabilistic model, improvements in target coverage and normal tissue sparing are possible. Our Markov model is flexible and has tunable parameters to adjust model performance to meet a range of criteria. Such a model may support the development of an adaptive paradigm for radiation therapy of cervical cancer.
A novel method for experimental characterization of large-angle scattered particles in scanned carbon-ion therapy41(2014); http://dx.doi.org/10.1118/1.4860256View Description Hide DescriptionPurpose:
It is essential to consider large-angle scattered particles in dose calculation models for therapeutic carbon-ion beams. However, it is difficult to measure the small dose contribution from large-angle scattered particles. In this paper, the authors present a novel method to derive the parameters describing large-angle scattered particles from the measured results.Methods:
The authors developed a new parallel-plate ionization chamber consisting of concentric electrodes. Since the sensitive volume of each channel is increased linearly with this type, it is possible to efficiently and easily detect small contributions from the large-angle scattered particles. The parameters describing the large-angle scattered particles were derived from pencil beam dose distribution in water measured with the new ionization chamber. To evaluate the validity of this method, the correction for the field-size dependence of the doses, “predicted-dose scaling factor,” was calculated with the new parameters.Results:
The predicted-dose scaling factor calculated with the new parameters was compared with the existing one. The difference between the new correction factor and the existing one was 1.3%. For target volumes of different sizes, the calculated dose distribution with the new parameters was in good agreement with the measured one.Conclusions:
Parameters describing the large-angle scattered particles can be efficiently and rapidly determined using the new ionization chamber. The authors confirmed that the field-size dependence of the doses could be compensated for by the new parameters. This method makes it possible to easily derive the parameters describing the large-angle scattered particles, while maintaining the dose calculation accuracy.
A new correction method serving to eliminate the parabola effect of flatbed scanners used in radiochromic film dosimetry41(2014); http://dx.doi.org/10.1118/1.4861098View Description Hide DescriptionPurpose:
The purpose of this study is the correction of the lateral scanner artifact, i.e., the effect that, on a large homogeneously exposed EBT3 film, a flatbed scanner measures different optical densities at different positions along thex axis, the axis parallel to the elongated light source. At constant dose, the measured optical densitiy profiles along this axis have a parabolic shape with significant dose dependent curvature. Therefore, the effect is shortly called the parabola effect. The objective of the algorithm developed in this study is to correct for the parabola effect. Any optical density measured at given position x is transformed into the equivalent optical density c at the apex of the parabola and then converted into the corresponding dose via the calibration of c versus dose.Methods:
For the present study EBT3 films and an Epson 10000XL scanner including transparency unit were used for the analysis of the parabola effect. The films were irradiated with 6 MV photons from an Elekta Synergy accelerator in a RW3 slab phantom. In order to quantify the effect, ten film pieces with doses graded from 0 to 20.9 Gy were sequentially scanned at eight positions along thex axis and at six positions along the z axis (the movement direction of the light source) both for the portrait and landscape film orientations. In order to test the effectiveness of the new correction algorithm, the dose profiles of an open square field and an IMRT plan were measured by EBT3 films and compared with ionization chamber and ionization chamber array measurement.Results:
The parabola effect has been numerically studied over the whole measuring field of the Epson 10000XL scanner for doses up to 20.9 Gy and for both film orientations. The presented algorithm transforms any optical density at positionx into the equivalent optical density that would be measured at the same dose at the apex of the parabola. This correction method has been validated up to doses of 5.2 Gy all over the scanner bed with 2D dose distributions of an open square photon field and an IMRT distribution.Conclusions:
The algorithm presented in this study quantifies and corrects the parabola effect of EBT3 films scanned in commonly used commercial flatbed scanners at doses up to 5.2 Gy. It is easy to implement, and no additional work steps are necessary in daily routine film dosimetry.
41(2014); http://dx.doi.org/10.1118/1.4856075View Description Hide DescriptionPurpose:
Electronic portal imaging devices (EPIDs) have proven to be useful tools for measuring several parameters of interest in linac quality assurance (QA). However, a method for measuring linac photon beam energy using EPIDs has not previously been reported. In this report, such a method is devised and tested, based on fitting a second order polynomial to the profiles of physically wedged beams, where the metric of interest is the second order coefficientα. The relationship between α and the beam quality index [percentage depth dose at 10 cm depth (PDD10)] is examined to produce a suitable calibration curve between these two parameters.Methods:
Measurements were taken in a water-tank for beams with a range of energies representative of the local QA tolerances about the nominal value 6 MV. In each case, the beam quality was found in terms of PDD10 for 100 × 100 mm2 square fields. EPID images of 200 × 200 mm2 wedged fields were then taken for each beam and the wedge profile was fitted in MATLAB 2010b (The MathWorks, Inc., Natick, MA). α was then plotted against PDD10 and fitted with a linear relation to produce the calibration curve. The uncertainty in α was evaluated by taking five repeat EPID images of the wedged field for a beam of 6 MV nominal energy. The consistency of measuring α was found by taking repeat measurements on a single linac over a three month period. The method was also tested at 10 MV by repeating the water-tank crosscalibration for a range of energies centered approximately about a 10 MV nominal value. Finally, the calibration curve from the test linac and that from a separate clinical machine were compared to test consistency of the method across machines in a matched fleet.Results:
The relationship betweenα and PDD10 was found to be strongly linear (R2 = 0.979) while the uncertainty in α was found to be negligible compared to that associated with measuring PDD10 in the water-tank (±0.3%). The repeat measurements over a three month period showed the method to be reasonably consistent (i.e., well within the limits defined by local QA tolerances). The measurements were repeated on a matched machine and the same linear relationship between α and PDD10 was observed. The results for both machines were found to be indistinguishable across the energy range of interest (i.e., across and close to the thresholds defined by local QA tolerances), hence a single relation could be established across a matched fleet. Finally, the experiment was repeated on both linacs at 10 MV, where the linear relationship between α and PDD10 was again observed.Conclusions:
The authors conclude that EPID image analysis of physically wedged beam profiles can be used to measure linac photon beam energy. The uncertainty in such a measurement is dominated by that associated with measuring PDD10 in the water-tank; hence, the accuracies of these two methods are directly comparable. This method provides a useful technique for quickly performing energy constancy measurements while saving significant clinical downtime for QA.
41(2014); http://dx.doi.org/10.1118/1.4859295View Description Hide DescriptionPurpose:
To describe a method for combining sliding window plans [intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT)] for use in treatment plan averaging, which is needed for Pareto surface navigation based multicriteria treatment planning.Methods:
The authors show that by taking an appropriately defined average of leaf trajectories of sliding window plans, the authors obtain a sliding window plan whose fluence map is the exact average of the fluence maps corresponding to the initial plans. In the case of static-beam IMRT, this also implies that the dose distribution of the averaged plan is the exact dosimetric average of the initial plans. In VMAT delivery, the dose distribution of the averaged plan is a close approximation of the dosimetric average of the initial plans.Results:
The authors demonstrate the method on three Pareto optimal VMAT plans created for a demanding paraspinal case, where the tumor surrounds the spinal cord. The results show that the leaf averaged plans yield dose distributions that approximate the dosimetric averages of the precomputed Pareto optimal plans well.Conclusions:
The proposed method enables the navigation of deliverable Pareto optimal plans directly, i.e., interactive multicriteria exploration of deliverable sliding window IMRT and VMAT plans, eliminating the need for a sequencing step after navigation and hence the dose degradation that is caused by such a sequencing step.
41(2014); http://dx.doi.org/10.1118/1.4860195View Description Hide DescriptionPurpose:
As clinics begin to use 3D metrics for intensity-modulated radiation therapy (IMRT) quality assurance, it must be noted that these metrics will often produce results different from those produced by their 2D counterparts. 3D and 2D gamma analyses would be expected to produce different values, in part because of the different search space available. In the present investigation, the authors compared the results of 2D and 3D gamma analysis (where both datasets were generated in the same manner) for clinical treatment plans.Methods:
Fifty IMRT plans were selected from the authors’ clinical database, and recalculated using Monte Carlo. Treatment planning system-calculated (“evaluated dose distributions”) and Monte Carlo-recalculated (“reference dose distributions”) dose distributions were compared using 2D and 3D gamma analysis. This analysis was performed using a variety of dose-difference (5%, 3%, 2%, and 1%) and distance-to-agreement (5, 3, 2, and 1 mm) acceptance criteria, low-dose thresholds (5%, 10%, and 15% of the prescription dose), and data grid sizes (1.0, 1.5, and 3.0 mm). Each comparison was evaluated to determine the average 2D and 3D gamma, lower 95th percentile gamma value, and percentage of pixels passing gamma.Results:
The average gamma, lower 95th percentile gamma value, and percentage of passing pixels for each acceptance criterion demonstrated better agreement for 3D than for 2D analysis for every plan comparison. The average difference in the percentage of passing pixels between the 2D and 3D analyses with no low-dose threshold ranged from 0.9% to 2.1%. Similarly, using a low-dose threshold resulted in a difference between the mean 2D and 3D results, ranging from 0.8% to 1.5%. The authors observed no appreciable differences in gamma with changes in the data density (constant difference: 0.8% for 2D vs 3D).Conclusions:
The authors found that 3D gamma analysis resulted in up to 2.9% more pixels passing than 2D analysis. It must be noted that clinical 2D versus 3D datasets may have additional differences—for example, if 2D measurements are made with a different dosimeter than 3D measurements. Factors such as inherent dosimeter differences may be an important additional consideration to the extra dimension of available data that was evaluated in this study.
41(2014); http://dx.doi.org/10.1118/1.4853375View Description Hide DescriptionPurpose:
In this report the authors present the validation of a Monte Carlo dose calculation algorithm (XiO EMC from Elekta Software) for electron beams.Methods:
Calculated and measured dose distributions were compared for homogeneous water phantoms and for a 3D heterogeneous phantom meant to approximate the geometry of a trachea and spine. Comparisons of measurements and calculated data were performed using 2D and 3D gamma index dose comparison metrics.Results:
Measured outputs agree with calculated values within estimated uncertainties for standard and extended SSDs for open applicators, and for cutouts, with the exception of the 17 MeV electron beam at extended SSD for cutout sizes smaller than 5 × 5 cm2. Good agreement was obtained between calculated and experimental depth dose curves and dose profiles (minimum number of measurements that pass a 2%/2 mm agreement 2D gamma index criteria for any applicator or energy was 97%). Dose calculations in a heterogeneous phantom agree with radiochromic film measurements (>98% of pixels pass a 3 dimensional 3%/2 mm γ-criteria) provided that the steep dose gradient in the depth direction is considered.Conclusions:
Clinically acceptable agreement (at the 2%/2 mm level) between the measurements and calculated data for measurements in water are obtained for this dose calculation algorithm. Radiochromic film is a useful tool to evaluate the accuracy of electron MC treatment planning systems in heterogeneous media.
Dosimetric effects of multileaf collimator leaf width on intensity-modulated radiotherapy for head and neck cancer41(2014); http://dx.doi.org/10.1118/1.4860155View Description Hide DescriptionPurpose:
The authors evaluated the effects of multileaf collimator (MLC) leaf width (2.5 vs. 5 mm) on dosimetric parameters and delivery efficiencies of intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) for head and neck (H&N) cancers.Methods:
The authors employed two types of mock phantoms: large-sized head and neck (LH&N) and small-sized C-shape (C-shape) phantoms. Step-and-shoot IMRT (S&S_IMRT) and VMAT treatment plans were designed with 2.5- and 5.0-mm MLC for both C-shape and LH&N phantoms. Their dosimetric characteristics were compared in terms of the conformity index (CI) and homogeneity index (HI) for the planning target volume (PTV), the dose to organs at risk (OARs), and the dose-spillage volume. To analyze the effects of the field and arc numbers, 9-field IMRT (9F-IMRT) and 13-field IMRT (13F-IMRT) plans were established for S&S_IMRT. For VMAT, single arc (VMAT1) and double arc (VMAT2) plans were established. For all plans, dosimetric verification was performed using the phantom to examine the relationship between dosimetric errors and the two leaf widths. Delivery efficiency of the two MLCs was compared in terms of beam delivery times, monitor units (MUs) per fraction, and the number of segments for each plan.Results:
2.5-mm MLC showed better dosimetric characteristics in S&S_IMRT and VMAT for C-shape, providing better CI for PTV and lower spinal cord dose and high and intermediate dose-spillage volume as compared with the 5-mm MLC (p < 0.05). However, no significant dosimetric benefits were provided by the 2.5-mm MLC for LH&N (p > 0.05). Further, beam delivery efficiency was not observed to be significantly associated with leaf width for either C-shape or LH&N. However, MUs per fraction were significantly reduced for the 2.5-mm MLC for the LH&N. In dosimetric error analysis, absolute dose evaluations had errors of less than 3%, while the Gamma passing rate was greater than 95% according to the 3%/3 mm criteria. There were no significant differences in dosimetric error between the 2.5- and 5-mm MLCs.Conclusions:
As compared with MLC of 5-mm leaf widths, MLC with finer leaf width (2.5-mm) can provide better dosimetric outcomes in IMRT for C-shape. However, the MLC leaf width may only have minor effects on dosimetric characteristics in IMRT for LH&N. The results of the present study will serve as a useful assessment standard when assigning or introducing equipment for the treatment of H&N cancers.
On the determination of reference levels for quality assurance of flattening filter free photon beams in radiation therapy41(2014); http://dx.doi.org/10.1118/1.4861817View Description Hide DescriptionPurpose:
New definitions for some dosimetric parameters for use in quality assurance of flattening filter free (FFF) beams generated by medical linear accelerators have been suggested. The present study aims to validate these suggestions and to propose possible reference levels.Methods:
The main characteristics of FFF photon beams were described in terms of: field size, penumbra, unflatness, slope, and peak-position parameters. Data were collected for 6 and 10 MV-FFF beams from three different Varian TrueBeam Linacs. Measurements were performed with a 2D-array (Starcheck system from PTW-Freiburg) and with the portal dosimetry method GLAaS utilizing the build-in portal imager of TrueBeam. Data were also compared to ion chamber measurements. A cross check validation has been performed on a FFF beam of 6 MV generated by a Varian Clinac-iX upgraded to FFF capability.Results
: All the parameters suggested to characterize the FFF beams resulted easily measurable and little variation was observed among different Linacs. Referring to two reference field sizes of 10 × 10 and 20 × 20 cm2, at SDD = 100 cm and d = dmax, from the portal dosimetry data, the following results (averaging X and Y profiles) were obtained. Field size: 9.95 ± 0.02 and 19.98 ± 0.03 cm for 6 MV-FFF (9.94 ± 0.02 and 19.98 ± 0.03 cm for 10 MV-FFF). Penumbra: 2.7 ± 0.3 and 2.9 ± 0.3 mm for 6 MV-FFF (3.1 ± 0.2 and 3.3 ± 0.3 for 10 MV-FFF). Unflatness: 1.11 ± 0.01 and 1.25 ± 0.01 for 6 MV-FFF (1.21 ± 0.01 and 1.50 ± 0.01 for 10 MV-FFF). Slope: 0.320 ± 0.020%/mm and 0.43 ± 0.015%/mm for 6 MV-FFF (0.657 ± 0.023%/mm and 0.795 ± 0.017%/mm for 10 MV-FFF). Peak Position −0.2 ± 0.2 and −0.4 ± 0.2 mm for 6 MV-FFF (−0.3 ± 0.2 and 0.7 ± 0.3 mm for 10 MV-FFF). Results would depend upon measurement depth. With thresholds set to at least 95% confidence level from the measured data and to account for possible variations between detectors and methods and experimental settings, a tolerance set of: 1 mm for field size and penumbra, 0.04 for unflatness, 0.1%/mm for slope, and 1 mm for peak position could be proposed from our data.Conclusions
: The parameters proposed for the characterization and routine control of stability of profiles of FFF beams appear to be a viable solution with a strong similarity to the conventional parameters used for flattened beams. The results from three different TrueBeams and the cross-validation against a Clinac-iX suggested the possible generalization of the methods and the possibility to use common tolerances for the parameters. The data showed also the reproducibility of beam characteristics among different systems (of the same vendor) and the resulting parameter values could therefore be possibly generalized.
41(2014); http://dx.doi.org/10.1118/1.4861711View Description Hide DescriptionPurpose:
Modulated electron radiotherapy (MERT) promises sparing of organs at risk for certain tumor sites. Any implementation of MERT treatment planning requires an accurate beam model. The aim of this work is the development of a beam model which reconstructs electron fields shaped using the Millennium photon multileaf collimator (MLC) (Varian Medical Systems, Inc., Palo Alto, CA) for a Varian linear accelerator (linac).Methods:
This beam model is divided into an analytical part (two photon and two electron sources) and a Monte Carlo (MC) transport through the MLC. For dose calculation purposes the beam model has been coupled with a macro MC dose calculation algorithm. The commissioning process requires a set of measurements and precalculated MC input. The beam model has been commissioned at a source to surface distance of 70 cm for a Clinac 23EX (Varian Medical Systems, Inc., Palo Alto, CA) and a TrueBeam linac (Varian Medical Systems, Inc., Palo Alto, CA). For validation purposes, measured and calculated depth dose curves and dose profiles are compared for four different MLC shaped electron fields and all available energies. Furthermore, a measured two-dimensional dose distribution for patched segments consisting of three 18 MeV segments, three 12 MeV segments, and a 9 MeV segment is compared with corresponding dose calculations. Finally, measured and calculated two-dimensional dose distributions are compared for a circular segment encompassed with a C-shaped segment.Results:
For 15 × 34, 5 × 5, and 2 × 2 cm2 fields differences between water phantom measurements and calculations using the beam model coupled with the macro MC dose calculation algorithm are generally within 2% of the maximal dose value or 2 mm distance to agreement (DTA) for all electron beam energies. For a more complex MLC pattern, differences between measurements and calculations are generally within 3% of the maximal dose value or 3 mm DTA for all electron beam energies. For the two-dimensional dose comparisons, the differences between calculations and measurements are generally within 2% of the maximal dose value or 2 mm DTA.Conclusions
: The results of the dose comparisons suggest that the developed beam model is suitable to accurately reconstruct photon MLC shaped electron beams for a Clinac 23EX and a TrueBeam linac. Hence, in future work the beam model will be utilized to investigate the possibilities of MERT using the photon MLC to shape electron beams.
41(2014); http://dx.doi.org/10.1118/1.4861713View Description Hide DescriptionPurpose:
Establish and validate a process of accurately irradiating small animals using the CyberKnife G4 System (version 8.5) with treatment plans designed to irradiate a hemisphere of a mouse brain based on microCT scanner images.Methods:
These experiments consisted of four parts: (1) building a mouse phantom for intensity modulated radiotherapy (IMRT) quality assurance (QA), (2) proving usability of a microCT for treatment planning, (3) fabricating a small animal positioning system for use with the CyberKnife's image guided radiotherapy (IGRT) system, and (4)in vivo verification of targeting accuracy. A set of solid water mouse phantoms was designed and fabricated, with radiochromic films (RCF) positioned in selected planes to measure delivered doses. After down-sampling for treatment planning compatibility, a CT image set of a phantom was imported into the CyberKnife treatment planning system—MultiPlan (ver. 3.5.2). A 0.5 cm diameter sphere was contoured within the phantom to represent a hemispherical section of a mouse brain. A nude mouse was scanned in an alpha cradle using a microCT scanner (cone-beam, 157 × 149 pixels slices, 0.2 mm longitudinal slice thickness). Based on the results of our positional accuracy study, a planning treatment volume (PTV) was created. A stereotactic body mold of the mouse was “printed” using a 3D printer laying UV curable acrylic plastic. Printer instructions were based on exported contours of the mouse's skin. Positional reproducibility in the mold was checked by measuring ten CT scans. To verify accurate dose delivery in vivo, six mice were irradiated in the mold with a 4 mm target contour and a 2 mm PTV margin to 3 Gy and sacrificed within 20 min to avoid DNA repair. The brain was sliced and stained for analysis.Results:
For the IMRT QA using a set of phantoms, the planned dose (6 Gy to the calculation point) was compared to the delivered dose measured via film and analyzed using Gamma analysis (3% and 3 mm). A passing rate of 99% was measured in areas of above 40% of the prescription dose. The final inverse treatment plan was comprised of 43 beams ranging from 5 to 12.5 mm in diameter (2.5 mm size increments are available up to 15 mm in diameter collimation). Using the Xsight Spine Tracking module, the CyberKnife system could not reliably identify and track the tiny mouse spine; however, the CyberKnife system could identify and track the fiducial markers on the 3D mold.In vivo positional accuracy analysis using the 3D mold generated a mean error of 1.41 mm ± 0.73 mm when fiducial markers were used for position tracking. Analysis of the dissected brain confirmed the ability to target the correct brain volume.Conclusions:
With the use of a stereotactic body mold with fiducial markers, microCT imaging, and resolution down-sampling, the CyberKnife system can successfully perform small-animal radiotherapy studies.
41(2014); http://dx.doi.org/10.1118/1.4861821View Description Hide DescriptionPurpose:
Excessive complexity in intensity-modulated radiation therapy (IMRT) plans increases the dose uncertainty, prolongs the treatment time, and increases the susceptibility to changes in patient or target geometry. To date, the tools for quantitative assessment of IMRT beam complexity are still lacking. In this study, The authors have sought to develop metrics to characterize different aspects of beam complexity and investigate the beam complexity for IMRT plans of different disease sites.Methods:
The authors evaluated the beam complexity scores for 65 step-and-shoot IMRT plans from three sites (prostate, head and neck, and spine) and 26 volumetric-modulated arc therapy (VMAT) plans for the prostate. On the basis of the beam apertures and monitor unit weights of all segments, the authors calculated the mean aperture area, extent of aperture shape irregularity, and degree of beam modulation for each beam. Then the beam complexity values were averaged to obtain the complexity metrics of the IMRT plans. The authors studied the correlation between the beam complexity metrics and the quality assurance (QA) results. Finally, the effects of treatment planning parameters on beam complexity were studied.Results:
The beam complexity scores were not uniform among the prostate IMRT beams from different gantry angles. The lateral beams had larger monitor units and smaller shape irregularity, while the anterior-posterior beams had larger modulation values. On average, the prostate IMRT plans had the smallest aperture irregularity, beam modulation, and normalized monitor units; the head and neck IMRT plans had large beam irregularity and beam modulation; and the spine stereotactic radiation therapy plans often had small beam apertures, which may have been associated with the relatively large discrepancies between planned and QA measured doses. There were weak correlations between the beam complexity scores and the measured dose errors. The prostate VMAT beams showed greater complexity than the prostate step-and-shoot IMRT beams. In the treatment planning process, the beam complexity increased as the minimum segment area decreased and as the number of optimization iterations and the maximum number of segments increased.Conclusions:
The proposed metrics were effective in characterizing the beam complexity of different disease sites and for different treatment modalities. Efforts should be made to reduce the unnecessary complexity of IMRT beams to minimize the radiation dose uncertainties.
Model-based dose calculations for COMS eye plaque brachytherapy using an anatomically realistic eye phantom41(2014); http://dx.doi.org/10.1118/1.4861715View Description Hide DescriptionPurpose
: To investigate the effects of the composition and geometry of ocular media and tissues surrounding the eye on dose distributions for COMS eye plaque brachytherapy with125I, 103Pd, or 131Cs seeds, and to investigate doses to ocular structures.Methods
: An anatomically and compositionally realistic voxelized eye model with a medial tumor is developed based on a literature review. Mass energy absorption and attenuation coefficients for ocular media are calculated. Radiation transport and dose deposition are simulated using the EGSnrc Monte Carlo user-code BrachyDose for a fully loaded COMS eye plaque within a water phantom and our full eye model for the three radionuclides. A TG-43 simulation with the same seed configuration in a water phantom neglecting the plaque and interseed effects is also performed. The impact on dose distributions of varying tumor position, as well as tumor and surrounding tissue media is investigated. Each simulation and radionuclide is compared using isodose contours, dose volume histograms for the lens and tumor, maximum, minimum, and average doses to structures of interest, and doses to voxels of interest within the eye.Results
: Mass energy absorption and attenuation coefficients of the ocular media differ from those of water by as much as 12% within the 20–30 keV photon energy range. For all radionuclides studied, average doses to the tumor and lens regions in the full eye model differ from those for the plaque in water by 8%–10% and 13%–14%, respectively; the average doses to the tumor and lens regions differ between the full eye model and the TG-43 simulation by 2%–17% and 29%–34%, respectively. Replacing the surrounding tissues in the eye model with water increases the maximum and average doses to the lens by 2% and 3%, respectively. Substituting the tumor medium in the eye model for water, soft tissue, or an alternate melanoma composition affects tumor dose compared to the default eye model simulation by up to 16%. In the full eye model simulations, the average dose to the lens is larger by 7%–9% than the dose to the center of the lens, and the maximum dose to the optic nerve is 17%–22% higher than the dose to the optic disk for all radionuclides. In general, when normalized to the same prescription dose at the tumor apex, doses delivered to all structures of interest in the full eye model are lowest for103Pd and highest for 131Cs, except for the tumor where the average dose is highest for 103Pd and lowest for 131Cs.Conclusions
: The eye is not radiologically water-equivalent, as doses from simulations of the plaque in the full eye model differ considerably from doses for the plaque in a water phantom and from simulated TG-43 calculated doses. This demonstrates the importance of model-based dose calculations for eye plaque brachytherapy, for which accurate elemental compositions of ocular media are necessary.