A Mascia

Clinical characterization of a proton beam continuous uniform scanning system with dose layer stacking

A proton beam delivery system on a gantry with continuous uniform scanning and dose layer stacking at the Midwest Proton Radiotherapy Institute has been commissioned and accepted for clinical use. This paper was motivated by a lack of guidance on the testing and characterization for clinical uniform scanning systems. As such, it describes how these tasks were performed with a uniform scanning beam delivery system. This paper reports the methods used and important dosimetric characteristics of radiation fields produced by the system. The commissioning data include the transverse and longitudinal dose distributions, penumbra, and absolute dose values. Using a 208 MeV cyclotrons proton beam, the system provides field sizes up to 20 and 30 cm in diameter for proton ranges in water up to 27 and 20 cm, respectively. The dose layer stacking method allows for the flexible construction of spread-out Bragg peaks with uniform modulation of up to 15 cm in water, at typical dose rates of 1-3 Gy/min. For measuring relative dose distributions, multielement ion chamber arrays, small-volume ion chambers, and radiographic films were employed. Measurements during the clinical commissioning of the system have shown that the lateral and longitudinal dose uniformity of 2.5% or better can be achieved for all clinically important field sizes and ranges. The measured transverse penumbra widths offer a slight improvement in comparison to those achieved with a double scattering beam spreading technique at the facility. Absolute dose measurements were done using calibrated ion chambers, thermoluminescent and alanine detectors. Dose intercomparisons conducted using various types of detectors traceable to a national standards laboratory indicate that the measured dosimetry data agree with each other within 5%.

Commissioning of output factors for uniform scanning proton beams

PURPOSE Current commercial treatment planning systems are not able to accurately predict output factors and calculate monitor units for proton fields. Patient-specific field output factors are thus determined by either measurements or empirical modeling based on commissioning data. The objective of this study is to commission output factors for uniform scanning beams utilized at the ProCure proton therapy centers. METHODS Using water phantoms and a plane parallel ionization chamber, the authors first measured output factors with a fixed 10 cm diameter aperture as a function of proton range and modulation width for clinically available proton beams with ranges between 4 and 31.5 cm and modulation widths between 2 and 15 cm. The authors then measured the output factor as a function of collimated field size at various calibration depths for proton beams of various ranges and modulation widths. The authors further examined the dependence of the output factor on the scanning area (i.e., uncollimated proton field), snout position, and phantom material. An empirical model was developed to calculate the output factor for patient-specific fields and the model-predicted output factors were compared to measurements. RESULTS The output factor increased with proton range and field size, and decreased with modulation width. The scanning area and snout position have a small but non-negligible effect on the output factors. The predicted output factors based on the empirical modeling agreed within 2% of measurements for all prostate treatment fields and within 3% for 98.5% of all treatment fields. CONCLUSIONS Comprehensive measurements at a large subset of available beam conditions are needed to commission output factors for proton therapy beams. The empirical modeling agrees well with the measured output factor data. This investigation indicates that it is possible to accurately predict output factors and thus eliminate or reduce time-consuming patient-specific output measurements for proton treatments.

Energy spectrum control for modulated proton beams

In proton therapy delivered with range modulated beams, the energy spectrum of protons entering the delivery nozzle can affect the dose uniformity within the target region and the dose gradient around its periphery. For a cyclotron with a fixed extraction energy, a rangeshifter is used to change the energy but this produces increasing energy spreads for decreasing energies. This study investigated the magnitude of the effects of different energy spreads on dose uniformity and distal edge dose gradient and determined the limits for controlling the incident spectrum. A multilayer Faraday cup (MLFC) was calibrated against depth dose curves measured in water for nonmodulated beams with various incident spectra. Depth dose curves were measured in a water phantom and in a multilayer ionization chamber detector for modulated beams using different incident energy spreads. Some nozzle entrance energy spectra can produce unacceptable dose nonuniformities of up to +/-21% over the modulated region. For modulated beams and small beam ranges, the width of the distal penumbra can vary by a factor of 2.5. When the energy spread was controlled within the defined limits, the dose nonuniformity was less than +/-3%. To facilitate understanding of the results, the data were compared to the measured and Monte Carlo calculated data from a variable extraction energy synchrotron which has a narrow spectrum for all energies. Dose uniformity is only maintained within prescription limits when the energy spread is controlled. At low energies, a large spread can be beneficial for extending the energy range at which a single range modulator device can be used. An MLFC can be used as part of a feedback to provide specified energy spreads for different energies.

Range and modulation dependencies for proton beam dose per monitor unit calculations

Calculations of dose per monitor unit (D/MU) are required in addition to measurements to increase patient safety in the clinical practice of proton radiotherapy. As in conventional photon and electron therapy, the D/MU depends on several factors. This study focused on obtaining range and modulation dependence factors used in D/MU calculations for the double scattered proton beam line at the Midwest Proton Radiotherapy Institute. Three dependencies on range and one dependency on modulation were found. A carefully selected set of measurements was performed to discern these individual dependencies. Dependencies on range were due to: (1) the stopping power of the protons passing through the monitor chamber; (2) the reduction of proton fluence due to nuclear interactions within the patient; and (3) the variation of proton fluence passing through the monitor chamber due to different source-to-axis distances (SADs) for different beam ranges. Different SADs are produced by reconfigurations of beamline elements to provide different field sizes and ranges. The SAD effect on the D/MU varies smoothly as the beam range is varied, except at the beam range for which the first scatterers are exchanged and relocated to accommodate low and high beam ranges. A geometry factor was devised to model the SAD variation effect on the D/MU. The measured D/MU variation as a function of range can be predicted within 1% using the three modeled dependencies on range. Investigation of modulated beams showed that an analytical formula can predict the D/MU dependency as a function of modulation to within 1.5%. Special attention must be applied when measuring the D/MU dependence on modulation to avoid interplay between range and SAD effects.

Validation of dosimetric field matching accuracy from proton therapy using a robotic patient positioning system

Large area, shallow fields are well suited to proton therapy. However, due to beam production limitations, such volumes typically require multiple matched fields. This is problematic due to the relatively narrow beam penumbra at shallow depths compared to electron and photon beams. Therefore, highly accurate dose planning and delivery is required. As the dose delivery includes shifting the patient for matched fields, accuracy at the 1–2 millimeter level in patient positioning is also required. This study investigates the dosimetric accuracy of such proton field matching by an innovative robotic patient positioner system (RPPS). The dosimetric comparisons were made between treatment planning system calculations, radiographic film and ionization chamber measurements. The results indicated good agreement amongst the methods and suggest that proton field matching by a RPPS is accurate and efficient. PACS number: 87.55.km

Dosimetric and radiobiologic comparison of 3D conformal, IMRT, VMAT and proton therapy for the treatment of early‐stage glottic cancer

This study aims to compare dosimetrically and radiobiologically 3D conformal, intensity modulated radiation therapy (IMRT), RapidArc (RA) volumetric modulated arc therapy and proton therapy techniques for early‐stage glottic cancer.

MO‐A‐213AB‐03: Commissioning of a Clinical Chair for Patients Treated in the Seated Position Using an Inclined Beam Line Treatment Room

PURPOSES A chair, coupled to a robotic patient positioning system (PPS) was manufactured to treat an intracranial tumor in a proton incline beam-line system. Treating patients in the seated position as accurately and efficiently as a treatment table requires the essential functions of isocentric rotation and a weight-sagging-correction algorithm for positioning patients in the seated position. METHODS AND MATERIALS The chair design incorporated a down-slope arm to achieve the desired beam-line height. To overcome this limitation of only 125 degree rotation on PPS, five indexed positions of the seat-base-plate (SBP) were implemented. An in-house developed optical tracking system using a six degree-of-freedom optical camera system was used to align the treatment room coordinate system with the chair coordinate system at all SBP positions. Furthermore, this optical tracking system quantified the sagging effect due to both the height and weight of a variety of patients. RESULTS The optical tracking system can measure accuracy of 0.1 degree and 0.1 mm. The SBP rotating axis was aligned within 0.1 degree to PPS rotating axis. A residual precession of chair rotation was found to be an ellipse with long axis of 2.0 mm and short axis of 1.0 mm. An additional 0.75 mm deviation occurred between rotating of SBP and PPS axes. Sagging tilt of 0.6 degree was found on the SBP for the home position for every additional 162 lbs load. This resulted in a 1.1cm shift (0.65 cm forward and 0.87 cm) for an isocenter 90 cm away from the SBP plate. CONCLUSIONS Using in-house developed optical tracking system, the overall maximum displacement of treatment chair system from isocenter is within 3.0 mm with known sagging characteristics. This characterization is essential to reduce the total treatment time and limited the number of X-rays required for accurate patient alignment in the seated position.

SU‐E‐T‐358: Dosimetric Effects of Beam Angle Arrangements in Lung Proton Therapy

Purpose: The Inclined Beam Line (IBL) is an innovative partial gantry design which provides two beam angles at 30 and 90 degrees with full flexibility of the patient positioning system of the gantry design. Compared to the full gantry design in proton therapy, the IBL is a simplified design allowing for less equipment maintenance, physics quality assurance, and costs. The purpose of this study was to demonstrate that IBL provides sufficient choice of beam angles and efficient beam delivery to treat most protonlung patients.Methods: Eight lung patients who had protontreatment at our center were selected for this study. We designed three treatment plans for each of the eight patients in supine position, using beam arrangements with (1) full gantry, (2) IBL, and (3) hybrid, i.e., a combination of a gantry plan and an IBL plan with the patients being treated with each plan in alternative days. Xio TPS (CMS, St. Louis, MO) was used to design treatment plans. Results: We have compared the dosimetric differences of the three planning strategies. The PTV D95 was within 1% for all three plans for each patient. On average, the lung V20, V10, and V5 were 3.6%/3.7%, 5.1%/3.7%, and 5.1%/1.6% higher for the IBL plans than that for the gantry/hybrid plans, respectively. Cord max dose, esophagus dose, and heart dose showed similar trends. Among all eight patients, IBL plan was not able to meet cord dose limit for only one patient who was treated for right posterior chest wall. Conclusions: Our results showed that seven out of the eight patients (88%) could be treated with full gantry, IBL, or hybrid plans with sufficient target coverage and reasonable critical structure sparing. Therefore, IBL was a sufficient protontreatment delivery method for most of the lung patients in this study.

SU‐EE‐A2‐06: Using Multi‐Element Detector Arrays for Commissioning Active Wobbling and Energy‐Stacking Proton Beams

Multi‐element detector arrays were constructed to characterize the properties of active wobbling and energy‐stacking proton beam commissioning. A multi‐layer ionization chamber (MLIC) array measured depth doses, and a multi‐pad ionization chamber (MPIC) array measured lateral profiles. The MLIC consists of 122 chambers with 1.82mm spatial resolution and has an effective physical density about 60% that of water. The MPIC consists of 128 chambers arranged in two 38cm long orthogonal lines with spatial resolution of 5mm within 10cm radius and 7mm outwardly. During performance tests on the MLIC and MPIC, good collection efficiency with superior reproducibility and linearity were achieved. The relative variation on the sensitivity for each individual chamber was carefully calibrated before use for proton beam characterization. The relatively small charge collection area (6mm in diameter) and volume (0.3 cm3) of each chamber has a well guarded lead and allows one to study the effect of field size on depth dose distributions for fields of approximately 2 cm to 10 cm in diameter. The MLIC is calibrated using a pristine proton beam with range 27cm in water. To calibrate the large dimensional MPIC, uniform lateral dose distributions in water within 1% were generated. Analytical functions were applied to fit measured depth dose and lateral distributions in water during the calibrations. With proper calibrations, the uncertainties of measured depth doses and lateral profiles with these multi‐element detector arrays were within 1% with respect to ones measured point by point with an ion chamber in a water phantom. Significant time savings for beam measurements were thus achieved.

SU‐E‐J‐76: Clinical Use of a Real‐Time Surface Image‐Guided Positioning and Tracking System in Proton Therapy

Topic of interest: Clinical applications of AlignRT 3-cameras real-time surface image-guided positioning system (IGPS) for positioning patients to reduce the number of X-ray images and tracking intra-fractional movements in proton therapy. PURPOSES To position patients and track the intra-fractional movements, the AlignRT system was implemented in proton incline-beam-line (IBL) at Procure Oklahoma-City center. METHODS The AlignRT3c system was configured near perpendicular to the gantry rotation for accommodating the X-ray IGPS. To evaluate positioning accuracy, more than 10 surfaces of each patient for ten patients with intracranial tumors were acquired after patients positioned by X-ray IGPS. Displacements between acquired surfaces and the reference surface taken at 1st day of treatment were examined. Intra-fractional movements with respiratory was studied with gated surface that allows setting the reference surface for patient at exhale during breathing. Intra-fractional movements due to respiratory were monitored on 10 sections of each patient for three patients with thoracic tumors. RESULTS Accuracy of positioning patient is 2.0 mm at both anterior-posterior and lateral directions, and is 3.5 mm in superior-inferior (SI) direction by aligning the surfaces of masks. Observed larger displacements along SI direction can be due to patients movements within the mask. Periodical displacements within 5 mm compared to its reference were seen for the three patients with thorax tumors. However, 10 mm sharp displacements with a few seconds were observed when patient moved the body. CONCLUSIONS We have implemented the first AlignRT3c IGPS for proton therapy for positioning patients within 2.0 mm, and successfully tracked intra-fractional respiratory motion during treatment after positioning patient.