Aliaksandr Karotki

Comparison of bulk electron density and voxel-based electron density treatment planning

The use of magnetic resonance imaging (MRI) alone for radiation planning is limited by the lack of electron density for dose calculations. The purpose of this work is to evaluate the dosimetric accuracy of using bulk electron density as a substitute for computed tomography (CT)‐derived electron density in intensity‐modulated radiation therapy (IMRT) treatment planning of head and neck (HN) cancers. Ten clinically‐approved, CT‐based IMRT treatment plans of HN cancer were used for this study. Three dose distributions were calculated and compared for each treatment plan. The first calculation used CT‐derived density and was assumed to be the most accurate. The second calculation used a homogeneous patient density of 1 g/cm3. For the third dose calculation, bone and air cavities were contoured and assigned a uniform density of 1.5 g/cm3 and 0 g/cm3, respectively. The remaining tissues were assigned a density of 1 g/cm3. The use of homogeneous anatomy resulted in up to 4%–5% deviations in dose distribution as compared to CT‐derived electron density calculations. Assigning bulk density to bone and air cavities significantly improved the accuracy of the dose calculations. All parameters used to describe planning target volume coverage were within 2% of calculations based on CT‐derived density. For organs at risk, most of the parameters were within 2%, with the few exceptions located in low‐dose regions. The data presented here show that if bone and air cavities are overridden with the proper density, it is feasible to use a bulk electron density approach for accurate dose calculation in IMRT treatment planning of HN cancers. This may overcome the problem of the lack of electron density information should MRI‐only simulation be performed. PACS number: 87.55.D‐

Hypofractionated Stereotactic Radiotherapy in Five Daily Fractions for Post-Operative Surgical Cavities in Brain Metastases Patients with and without Prior Whole Brain Radiation

Our purpose was to report efficacy of hypofractionated cavity stereotactic radiotherapy (HCSRT) in patients with and without prior whole brain radiotherapy (WBRT). 32 surgical cavities in 30 patients (20 patients/21 cavities had no prior WBRT and 10 patients/11 cavities had prior WBRT) were treated with image-guided linac stereotactic radiotherapy. 7 of the 10 prior WBRT patients had “resistant” local disease given prior surgery, post-operative WBRT and a re-operation, followed by salvage HCSRT. The clinical target volume was the post-surgical cavity, and a 2-mm margin applied as planning target volume. The median total dose was 30 Gy (range: 25–37.5 Gy) in 5 fractions. In the no prior and prior WBRT cohorts, the median follow-up was 9.7 months (range: 3.0–23.6) and 15.3 months (range: 2.9–39.7), the median survival was 23.6 months and 39.7 months, and the 1-year cavity local recurrence progression-free survival (LRFS) was 79 and 100%, respectively. At 18 months the LRFS dropped to 29% in the prior WBRT cohort. Grade 3 radiation necrosis occurred in 3 prior WBRT patients. We report favorable outcomes with HCSRT, and well selected patients with prior WBRT and “resistant” disease may have an extended survival favoring aggressive salvage HCSRT at a moderate risk of radiation necrosis.

4DCT Simulation With Synchronized Contrast Injection in Liver SBRT Patients

Background/Purpose: Delivering stereotactic body radiotherapy for liver metastases remains a challenge because of respiratory motion and poor visibility without intravenous contrast. The purpose of this article is to describe a novel and simple computed tomography (CT) simulation process of integrating timed intravenous contrast that could overcome the uncertainty of target delineation. Methods and Results: The simulation involves two 4-dimensional CT (4DCT) scans. The first scan only encompasses the immediate region of the tumor and surrounding tissue, which reduces the 4DCT scan time so that it can be optimally timed with intravenous contrast injection. The second 4DCT scan covers a larger volume and is used as the primary CT data set for dose calculation, as well as patient setup verification on the treatment unit. The combination of the two 4DCT scans allows us to optimally visualize liver metastases over all phases of the breathing cycle while simultaneously acquiring a long enough 4DCT data set that is suitable for planning and patient setup verification. Conclusion: This simulation technique allows for a better target definition when treating liver metastases, without being invasive.

Practical dose delivery verification of craniospinal IMRT

Craniospinal irradiation (CSI) using IMRT allows dose sparing to organs‐at‐risk (OAR) whilst conforming the dose to the target volume. Due to the complexity of treatment involving several isocenters, the dose distribution created by the inverse‐planned segmented fields must be verified prior to treatment. We propose and test methods to verify dose delivery using commonly available dosimetry equipment for commissioning and routine patient‐specific dose verification of craniospinal IMRT. Ten patients treated with conventional CSI were retrospectively planned with a 3‐isocenter (cranial, upper spine, and lower spine) IMRT technique. The isocenters were placed 25–27 cm away from each other in the longitudinal direction but in the same lateral and anterioposterior positions. The planning target volume (PTV) was defined as the brain with a 0.5 cm margin and spinal canal with a 1.0 cm margin. The plans were prescribed to 36 Gy in 20 fractions to the PTV mean dose. Eleven beams (five cranial, three upper spine, and three lower spine) were optimized simultaneously. The dose delivered by the IMRT plans was then recalculated on several different phantoms and measured using the following methods: 1) ionization chamber inserted in a cylindrical phantom, positioned in the junction regions between cranial/upper‐spine isocenters and upper‐/lower‐spine isocenters; 2) MapCHECK centered in the overlap regions; and 3) ArcCHECK measurement with beams from each isocenter. For 1) ±3% dose difference and for 2) and 3) ≥95% of measured points with a γ‐index <1 for 3% dose difference and 3 mm distance‐to‐agreement were deemed clinically acceptable. The median (range) planned to measured dose differences for the ionization chamber is 0.4% (−1.5% to 3.0%) for the cranial/upper‐spine field and 1.8% (−0.8% to 2.6%) for the upper‐/lower‐spine field overlap region. The median (range) percentage of MapCHECK diodes with a γ index <1 for 3%/3 mm criterion is 98.0% (95.3% to 99.7%) for the cranial/upper‐spine and 97.3% (95.0% to 99.6%) for the upper‐/lower‐spine field overlap regions. The median (range) percentage of ArcCHECK diodes with a γ index <1 for 3%/3 mm criterion is 99.7% (97.1% to 100%). Three different methods of verifying craniospinal IMRT were compared and tested. All techniques offer different benefits and together can be used for 1) commissioning the treatment technique and, separately, for 2) patient‐specific pretreatment verification measurements. PACS number: 87.55.kmCraniospinal irradiation (CSI) using IMRT allows dose sparing to organs-at-risk (OAR) whilst conforming the dose to the target volume. Due to the complexity of treatment involving several isocenters, the dose distribution created by the inverse-planned segmented fields must be verified prior to treatment. We propose and test methods to verify dose delivery using commonly available dosimetry equipment for commissioning and routine patient-specific dose verification of craniospinal IMRT. Ten patients treated with conventional CSI were retrospectively planned with a 3-isocenter (cranial, upper spine, and lower spine) IMRT technique. The isocenters were placed 25-27 cm away from each other in the longitudinal direction but in the same lateral and anterioposterior positions. The planning target volume (PTV) was defined as the brain with a 0.5 cm margin and spinal canal with a 1.0 cm margin. The plans were prescribed to 36 Gy in 20 fractions to the PTV mean dose. Eleven beams (five cranial, three upper spine, and three lower spine) were optimized simultaneously. The dose delivered by the IMRT plans was then recalculated on several different phantoms and measured using the following methods: 1) ionization chamber inserted in a cylindrical phantom, positioned in the junction regions between cranial/upper-spine isocenters and upper-/lower-spine isocenters; 2) MapCHECK centered in the overlap regions; and 3) ArcCHECK measurement with beams from each isocenter. For 1) ±3% dose difference and for 2) and 3) ≥95% of measured points with a γ-index <1 for 3% dose difference and 3 mm distance-to-agreement were deemed clinically acceptable. The median (range) planned to measured dose differences for the ionization chamber is 0.4% (-1.5% to 3.0%) for the cranial/upper-spine field and 1.8% (-0.8% to 2.6%) for the upper-/lower-spine field overlap region. The median (range) percentage of MapCHECK diodes with a γ index <1 for 3%/3 mm criterion is 98.0% (95.3% to 99.7%) for the cranial/upper-spine and 97.3% (95.0% to 99.6%) for the upper-/lower-spine field overlap regions. The median (range) percentage of ArcCHECK diodes with a γ index <1 for 3%/3 mm criterion is 99.7% (97.1% to 100%). Three different methods of verifying craniospinal IMRT were compared and tested. All techniques offer different benefits and together can be used for 1) commissioning the treatment technique and, separately, for 2) patient-specific pretreatment verification measurements. PACS number: 87.55.km.

Poster — Thur Eve — 16: 4DCT simulation with synchronized contrast injection of liver SBRT patients

Stereotactic body radiation therapy (SBRT) has recently emerged as a valid option for treating liver metastases. SBRT delivers highly conformai dose over a small number of fractions. As such it is particularly sensitive to the accuracy of target volume delineation by the radiation oncologist. However, contouring liver metastases remains challenging for the following reasons. First, the liver usually undergoes significant motion due to respiration. Second, liver metastases are often nearly indistinguishable from the surrounding tissue when using computed tomography (CT) for imaging making it difficult to identify and delineate them. Both problems can be overcome by using four dimensional CT (4DCT) synchronized with intravenous contrast injection. We describe a novel CT simulation process which involves two 4DCT scans. The first scan captures the tumor and immediately surrounding tissue which in turn reduces the 4DCT scan time so that it can be optimally timed with intravenous contrast injection. The second 4DCT scan covers a larger volume and is used as the primary CT dataset for dose calculation, as well as patient setup verification on the treatment unit. The combination of two 4DCT scans, short and long, allows visualization of the liver metastases over all phases of breathing cycle while simultaneously acquiring long enough 4DCT dataset suitable for planning and patient setup verification.

Reliability of contour-based volume calculation for radiosurgery

OBJECT Determining accurate target volume is critical for both prescribing and evaluating stereotactic radiosurgery (SRS) treatments. The aim of this study was to determine the reliability of contour-based volume calculations made by current major SRS platforms. METHODS Spheres ranging in diameter from 6.4 to 38.2 mm were scanned and then delineated on imaging studies. Contour data sets were subsequently exported to 6 SRS treatment-planning platforms for volume calculations and comparisons. This procedure was repeated for the case of a patient with 12 metastatic lesions distributed throughout the brain. Both the phantom and patient datasets were exported to a stand-alone workstation for an independent volume-calculation analysis using a series of 10 algorithms that included approaches such as slice stacking, surface meshing, point-cloud filling, and so forth. RESULTS Contour data-rendered volumes exhibited large variations across the current SRS platforms investigated for both the phantom (-3.6% to 22%) and patient case (1.0%-10.2%). The majority of the clinical SRS systems and algorithms overestimated the volumes of the spheres, compared with their known physical volumes. An independent algorithm analysis found a similar trend in variability, and large variations were typically associated with small objects whose volumes were < 0.4 cm(3) and with those objects located near the end-slice of the scan limits. CONCLUSIONS Significant variations in volume calculation were observed based on data obtained from the SRS systems that were investigated. This observation highlights the need for strict quality assurance and benchmarking efforts when commissioning SRS systems for clinical use and, moreover, when conducting multiinstitutional cross-SRS platform clinical studies.

Poster - 55: Active Breathing Coordinator Based Treatment of Liver SBRT Patients

Purpose: Accuracy of treatment delivery for liver SBRT patients can be compromised by breathing induced motion. Recently we started using active breathing coordinator (ABC) to “freeze” the breathing motion. This work describes our initial experience with ABC based treatment of liver SBRT patients. Methods: Patients are treated in maximum exhale state with a minimum required breath hold time of 20 s. Fluoroscopy is used to assess diaphragm stability before both simulation and treatment. Depending on the proximity of organs at risk, 30–60 Gy are given in five fractions every other day and delivered via VMAT. CBCT is used for patient setup verification with robotic couch compensating for translations/rotations. An additional CBCT is acquired after every fraction to confirm patients stability during treatment. Results: Six patients have successfully been treated using the ABC protocol so far with an approximate treatment time of 1 h. CBCT acquired after the treatment suggests that patients are stable and the liver position, when locked by ABC, is reproducible throughout the treatment (average deviation 1.9 mm). The major immediate benefit of using ABC is a drastic improvement in image quality of the CT simulation as well as CBCT images. Conclusions: ABC eliminates breathing motion and, as such, substantially improves the quality of the images acquired at CT simulation as well as CBCT images leading to more reliable dose delivery. The position of the liver remains stable for the duration of treatment when using the ABC system. The treatment is well tolerated by the patients.

SU-E-T-477: An Efficient Dose Correction Algorithm Accounting for Tissue Heterogeneities in LDR Brachytherapy

PURPOSE Seed brachytherapy is currently used for adjuvant radiotherapy of early stage prostate and breast cancer patients. The current standard for calculation of dose surrounding the brachytherapy seeds is based on American Association of Physicist in Medicine Task Group No. 43 (TG-43 formalism) which generates the dose in homogeneous water medium. Recently, AAPM Task Group No. 186 emphasized the importance of accounting for tissue heterogeneities. This can be done using Monte Carlo (MC) methods, but it requires knowing the source structure and tissue atomic composition accurately. In this work we describe an efficient analytical dose inhomogeneity correction algorithm implemented using MIM Symphony treatment planning platform to calculate dose distributions in heterogeneous media. METHODS An Inhomogeneity Correction Factor (ICF) is introduced as the ratio of absorbed dose in tissue to that in water medium. ICF is a function of tissue properties and independent of source structure. The ICF is extracted using CT images and the absorbed dose in tissue can then be calculated by multiplying the dose as calculated by the TG-43 formalism times ICF. To evaluate the methodology, we compared our results with Monte Carlo simulations as well as experiments in phantoms with known density and atomic compositions. RESULTS The dose distributions obtained through applying ICF to TG-43 protocol agreed very well with those of Monte Carlo simulations as well as experiments in all phantoms. In all cases, the mean relative error was reduced by at least 50% when ICF correction factor was applied to the TG-43 protocol. CONCLUSION We have developed a new analytical dose calculation method which enables personalized dose calculations in heterogeneous media. The advantages over stochastic methods are computational efficiency and the ease of integration into clinical setting as detailed source structure and tissue segmentation are not needed. University of Toronto, Natural Sciences and Engineering Research Council of Canada.

SU-E-T-488: Treatment of a Unique CNS Patient with Tomotherapy

Purpose: We describe a whole spinal cord, cauda equine, and brainstem radiation treatment using an in‐house developed tomotherapy approach for a unique patient diagnosed with an extramedullary spinal melanocytoma with leptomeningeal seeding, treated with 48.6 Gy in 28 fractions. Methods and Materials: Given that the prescribed dose is within the range of tolerance to the spinal cord, tomotherapy was chosen to take advantage of the superior dose uniformity achievable with this technology and ability to deliver modulated radiotherapy in a single treatment to a long volume. The patient was treated supine and immobilized with a thermoplastic mask for the head and shoulders and a long Vac‐Lok bag for the body. The CTV consisted of the entire spinal cord, thecal sac to the level of S2 and brainstem. A 1 cm margin was applied to create the PTV. Jaws, pitch and the modulation factor were set to 5 cm, 0.43 and 2.5, respectively. Before each treatment, the treated volume was imaged for setup verification using the integrated megavoltage CT (MVCT). Weekly the patient was also imaged post‐ treatment to confirm setup stability. Results: The patient is finishing treatment at the time of abstract submission. A highly conformal dose distribution was created with doses to the organs at risk within their tolerance limits. The beam on time was 17 minutes. Patient setup proved to be trouble‐free and reproducible. The total patient‐on‐the‐bed time was approximately one hour. The 1 cm PTV margin was adequate according to pre‐ and post‐treatment MVCT image analysis. Conclusions: Tomotherapy is a safe and effective tool for treating long CNS volumes to high dose. It allows avoiding junctions and sparing healthy CNStissue and other organs at risk. A relatively simple immobilization technique used for this patient proved to be stable and reproducible with a 1 cm PTV margin.

Poster — Thur Eve — 39: Dosimetric Evaluation of Bulk Electron Density Based Treatment Planning in IMRT Head and Neck Patients: Can It Be Used for MRI‐Based Planning?

One limitation of using MRI alone for radiation planning is the lack of electron density for dose calculation. We evaluated the dosimetric accuracy of using bulk density overrides as a substitute for CT-derived densities in IMRT treatment planning for head and neck cancer. Ten clinically-approved, CT-based treatment plans were used for this study. Three dose distributions were calculated for each treatment plan. The first calculation used CT-derived density as a basis for heterogeneity correction. The second calculation assumed a homogeneous patient density of 1 g/cm3. For the third dose calculation we contoured bones and air cavities and assigned them a uniform density of 1.5 g/cm3 and 0 g/cm3, respectively. The remaining tissue was assigned a density of 1 g/cm3. All three calculations utilized identical beam parameters (angles, segments and MUs). Actual MR images were not used for contouring to avoid effects of gradient distortion and volumetric uncertainties associated with them. All calculations were done using the Collapsed Cone Superposition algorithm in the Pinnacle3 treatment planning system. Our results show that the assignment of bulk density to bones and air cavities was a feasible approach to IMRT treatment planning for head and neck patients. In almost all cases, the dosimetric results were within 2% of the treatment plans based on CT-derived density. This method may overcome the lack of electron density information in MR-based planning. The use of homogeneous geometry, while simpler and less time consuming, resulted in unacceptably high errors in the dose distribution compared to the nominal plan. This research project is supported by Philips Medical Systems.