Austen Curcuru

Technical Note: Magnetic field effects on Gafchromic‐film response in MR‐IGRT

PURPOSE Magnetokinetic changes may affect crystal orientation and polymerization within the active layer of radiochromic film (RCF). This effect is investigated in a magnetic resonance image-guided radiotherapy unit within the context of film dosimetry. METHODS Gafchromic EBT2 RCF was irradiated in a 30 × 30 × 30 cm3 solid water phantom using a Co-60 MRI guided radiotherapy system (B = 0.35 T) under normal operating conditions, and under the exact conditions and setup without a magnetic field. Fifteen 20.3 × 25.4 cm2 EBT2 film sheets were placed at three different depths (d = 0.5, 5, and 10 cm) using five different treatment plans. The plans were computed using the MRIdian (ViewRay, Inc.) treatment planning system to deliver doses between 0 and 17.6 Gy. Films were analyzed before and after irradiation to obtain the net optical density (netOD) for each color channel separately. Scanning electron microscope (SEM) images were obtained to compare the active layer of selected samples. RESULTS The results indicated that the red channel netOD decreased between 0.013 and 0.123 (average of 0.060 ± 0.033) for doses above 2.8 Gy, with a linear increase in this effect for higher doses. Green channel netOD showed similar results with a decrease between 0.012 and 0.105 (average of 0.041 ± 0.027) for doses above 3.5 Gy. The blue channel showed the weakest effect with a netOD decrease between 0.013 and 0.029 (average of 0.020 ± 0.006) for doses above 8.0 Gy. SEM images show changes in crystal orientation within active layer in RCF exposed in a magnetic field. CONCLUSIONS The presence of a magnetic field affects crystal orientation and polymerization during irradiation, where netOD decreased by an average of 8.7%, 8.0%, and 4.3% in the red, green, and blue channels, respectively. The under response was dependent on dose and differed by up to 15% at 17.6 Gy.

Stereotactic MR-guided Online Adaptive Radiation Therapy (SMART) for Ultra-Central Thorax Malignancies: Results of a Phase I Trial

Purpose Stereotactic body radiation therapy (SBRT) is an effective treatment for oligometastatic or unresectable primary malignancies, although target proximity to organs at risk (OARs) within the ultracentral thorax (UCT) limits safe delivery of an ablative dose. Stereotactic magnetic resonance (MR)–guided online adaptive radiation therapy (SMART) may improve the therapeutic ratio using reoptimization to account for daily variation in target and OAR anatomy. This study assessed the feasibility of UCT SMART and characterized dosimetric and clinical outcomes in patients treated for UCT lesions on a prospective phase 1 trial. Methods and Materials Five patients with oligometastatic (n = 4) or unresectable primary (n = 1) UCT malignancies underwent SMART. Initial plans prescribed 50 Gy in 5 fractions with goal 95% planning target volume (PTV) coverage by 95% of prescription, subject to strict OAR constraints. Daily real-time online adaptive plans were created as needed to preserve hard OAR constraints, escalate PTV dose, or both, based on daily setup MR image set anatomy. Treatment times, patient outcomes, and dosimetric comparisons were prospectively recorded. Results All initial and daily adaptive plans met strict OAR constraints based on simulation and daily setup MR imaging anatomy, respectively. Four of the 5 patients received ≥1 adapted fraction. Ten of the 25 total delivered fractions were adapted. A total of 30% of plan adaptations were performed to improve PTV coverage; 70% were for reversal of ≥1 OAR violation. Local control by Response Evaluation Criteria in Solid Tumors was 100% at 3 and 6 months. No grade ≥3 acute (within 6 months of radiation completion) treatment-related toxicities were identified. Conclusions SMART may allow PTV coverage improvement and/or OAR sparing compared with nonadaptive SBRT and may widen the therapeutic index of UCT SBRT. In this small prospective cohort, we found that SMART was clinically deliverable to 100% of patients, although treatment delivery times surpassed our predefined, timing-based feasibility endpoint. This technique is well tolerated, offering excellent local control with no identified acute grade ≥3 toxicity.

TU-AB-BRA-12: Quality Assurance of An Integrated Magnetic Resonance Image Guided Adaptive Radiotherapy Machine Using Cherenkov Imaging

PURPOSE To investigate the viability of using Cherenkov imaging as a fast and robust method for quality assurance tests in the presence of a magnetic field, where other instruments can be limited. METHODS Water tank measurements were acquired from a clinically utilized adaptive magnetic resonance image guided radiation therapy (MR-IGRT) machine with three multileaf-collimator equipped 60Co sources. Cherenkov imaging used an intensified charge coupled device (ICCD) camera placed 3.5m from the treatment isocenter, looking down the bore of the 0.35T MRI into a water tank. Images were post-processed to make quantitative comparison between Cherenkov light intensity with both film and treatment planning system predictions, in terms of percent depth dose curves as well as lateral beam profile measurements. A TG-119 commissioning test plan (C4: C-Shape) was imaged in real-time at 6.33 frames per second to investigate the temporal and spatial resolution of the Cherenkov imaging technique. RESULTS A .33mm/pixel Cherenkov image resolution was achieved across 1024×1024 pixels in this setup. Analysis of the Cherenkov image of a 10.5×10.5cm treatment beam in the water tank successfully measured the beam width at the depth of maximum dose within 1.2% of the film measurement at the same point. The percent depth dose curve for the same beam was on average within 2% of ionization chamber measurements for corresponding depths between 3-100mm. Cherenkov video of the TG-119 test plan provided qualitative agreement with the treatment planning system dose predictions, and a novel temporal verification of the treatment. CONCLUSIONS Cherenkov imaging was successfully used to make QA measurements of percent depth dose curves and cross beam profiles of MRI-IGRT radiotherapy machines after only several seconds of beam-on time and data capture; both curves were extracted from the same data set. Video-rate imaging of a dynamic treatment plan provided new information regarding temporal dose deposition. This study has been funded by NIH grants R21EB17559 and R01CA109558, as well as Norris Cotton Cancer Center Pilot funding.

Performance of a multi leaf collimator system for MR-guided radiation therapy

Purpose: The purpose of this study was to investigate and characterize the performance of a Multi Leaf Collimator (MLC) designed for Cobalt‐60 based MR‐guided radiation therapy system in a 0.35 T magnetic field. Methods: The MLC design and unique assembly features in the ViewRay MRIdian system were first reviewed. The RF cage shielding of MLC motor and cables were evaluated using ACR phantoms with real‐time imaging and quantified by signal‐to‐noise ratio. The dosimetric characterizations, including the leaf transmission, leaf penumbra, tongue‐and‐groove effect, were investigated using radiosensitive films. The output factor of MLC‐defined fields was measured with ionization chambers for both symmetric fields from 2.1 × 2.1 cm2 to 27.3 × 27.3 cm2 and asymmetric fields from 10.5 × 10.5 cm2 to 10.5 × 2.0 cm2. Multi leaf collimator (MLC) positional accuracy was assessed by delivering either a picket fence (PF) style pattern on radiochromic films with wire‐jig phantom or double and triple‐rectangular patterns on ArcCheck‐MR (Sun Nuclear, Melbourne, FL, USA) with gamma analysis as the pass/fail indicator. Leaf speed tests were performed to assess the capability of full range leaf travel within manufactures specifications. Multi leaf collimator plan delivery reproducibility was tested by repeatedly delivering both open fields and fields with irregular shaped segments over 1‐month period. Results: Comparable SNRs within 4% were observed for MLC moving and stationary plans on vendor‐reconstructed images, and the direct k‐space reconstructed images showed that the three SNRs are within 1%. The maximum leaf transmission for all three MLCs was less than 0.35% and the average leakage was 0.153 ± 0.006%, 0.151 ± 0.008%, and 0.159 ± 0.015% for head 1, 2, and 3, respectively. Both the leaf edge and leaf end penumbra showed comparable values within 0.05 cm, and the measured values are within 0.1 cm with TPS values. The leaf edge TG effect indicated 10% underdose and the leaf end TG showed a shifted dose distribution with 0.3 cm offset. The leaf positioning test showed a 0.2 cm accuracy in the PF style test, and a gamma passing rate above 96% was observed with a 3%/2 mm criteria when comparing the measured double/triple‐rectangular pattern fluence with TPS calculated fluence. The average leaf speed when executing the test plan fell in a range from 1.86 to 1.95 cm/s. The measured and TPS calculated output factors were within 2% for squared fields and within 3% for rectangular fields. The reproducibility test showed the deviation of output factors were well within 2% for square fields and the gamma passing rate within 1.5% for fields with irregular segments. The Monte Carlo predicted output factors were within 2% compared to TPS values. 15 out of the 16 IMRT plans have gamma passing rate more than 98% compared to the TPS fluence with an average passing rate of 99.1 ± 0.6%. Conclusion: The MRIdian MLC has a good RF noise shielding design, low radiation leakage, good positioning accuracy, comparable TG effect, and can be modeled by an independent Monte Carlo calculation platform.

A method to reconstruct and apply 3D primary fluence for treatment delivery verification

Abstract Motivation In this study, a method is reported to perform IMRT and VMAT treatment delivery verification using 3D volumetric primary beam fluences reconstructed directly from planned beam parameters and treatment delivery records. The goals of this paper are to demonstrate that 1) 3D beam fluences can be reconstructed efficiently, 2) quality assurance (QA) based on the reconstructed 3D fluences is capable of detecting additional treatment delivery errors, particularly for VMAT plans, beyond those identifiable by other existing treatment delivery verification methods, and 3) QA results based on 3D fluence calculation (3DFC) are correlated with QA results based on physical phantom measurements and radiation dose recalculations. Methods Using beam parameters extracted from DICOM plan files and treatment delivery log files, 3D volumetric primary fluences are reconstructed by forward‐projecting the beam apertures, defined by the MLC leaf positions and modulated by beam MU values, at all gantry angles using first‐order ray tracing. Treatment delivery verifications are performed by comparing 3D fluences reconstructed using beam parameters in delivery log files against those reconstructed from treatment plans. Passing rates are then determined using both voxel intensity differences and a 3D gamma analysis. QA sensitivity to various sources of errors is defined as the observed differences in passing rates. Correlations between passing rates obtained from QA derived from both 3D fluence calculations and physical measurements are investigated prospectively using 20 clinical treatment plans with artificially introduced machine delivery errors. Results Studies with artificially introduced errors show that common treatment delivery problems including gantry angle errors, MU errors, jaw position errors, collimator rotation errors, and MLC leaf position errors were detectable at less than normal machine tolerances. The reported 3DFC QA method has greater sensitivity than measurement‐based QA methods. Statistical analysis‐based Spearmans correlations shows that the 3DFC QA passing rates are significantly correlated with passing rates of physical phantom measurement‐based QA methods. Conclusion Among measurement‐less treatment delivery verification methods, the reported 3DFC method is less demanding than those based on full dose re‐calculations, and more comprehensive than those that solely checks beam parameters in treatment log files. With QA passing rates correlating to measurement‐based passing rates, the 3DFC QA results could be useful for complementing the physical phantom measurements, or verifying treatment deliveries when physical measurements are not available. For the past 4+ years, the reported method has been implemented at authors’ institution 1) as a complementary metric to physical phantom measurements for pretreatment, patient‐specific QA of IMRT and VMAT plans, and 2) as an important part of the log file‐based automated verification of daily patient treatment deliveries. It has been demonstrated to be useful in catching both treatment plan data transfer errors and treatment delivery problems.

How feasible is remote 3D dosimetry for MR guided Radiation Therapy (MRgRT)

To develop and apply a remote dosimetry protocol with PRESAGE® radiochromic plastic and optical-CT readout in the validation of MRI guided radiation therapy (MRgRT) treatments (MRIdian® by ViewRay®). Through multi-institutional collaboration we performed PRESAGE® dosimetry studies in 4ml cuvettes to investigate dose-response linearity, MR-compatibility, and energy-independence. An open calibration field and symmetrical 3-field plans were delivered to 10cm diameter PRESAGE® to examine percent depth dose and response uniformity under a magnetic field. Evidence of non-linear dose response led to a large volume PRESAGE® study where small corrections were developed for temporally- and spatially-dependent behaviors observed between irradiation and delayed readout. TG-119 plans were created in the MRIdian® TPS and then delivered to 14.5cm 2kg PRESAGE® dosimeters. Through the domestic investigation of an off-site MRgRT system, a refined 3D remote dosimetry protocol is presented capable of validation of advanced MRgRT radiation treatments.

TH‐CD‐BRA‐02: 3D Remote Dosimetry for MRI‐Guided Radiation Therapy: A Hybrid Approach

PURPOSE To validate the dosimetric accuracy of a commercially available MR-IGRT system using a combination of 3D dosimetry measurements (with PRESAGE(R) radiochromic plastic and optical-CT readout) and an in-house developed GPU-accelerated PENELOPE Monte-Carlo dose calculation system. METHODS 60 Co IMRT subject to a 0.35T lateral magnetic field has recently been commissioned in our institution following AAPMs TG-119 recommendations. We performed PRESAGE(R) sensitivity studies in 4ml cuvettes to verify linearity, MR-compatibility, and energy-independence. Using 10cm diameter PRESAGE(R), we delivered an open calibration field to examine the percent depth dose and a symmetrical 3-field plan with three adjacent regions of varying dose to determine uniformity within the dosimeter under a magnetic field. After initial testing, TG-119 plans were created in the TPS and then delivered to 14.5cm 2kg PRESAGE(R) dosimeters. Dose readout was performed via optical-CT at a second institution specializing in remote 3D dosimetry. Absolute dose was measured using an IBA CC01 ion chamber and the institution standard patient-specific QA methods were used to validate plan delivery. Calculated TG-119 plans were then compared with an independent Monte Carlo dose calculation (gPENELOPE). RESULTS PRESAGE(R) responds linearly (R2 =0.9996) to 60 Co irradiation, in the presence of a 0.35T magnetic field, with a sensitivity of 0.0305(±0.003)cm-1 Gy-1 , within 1% of a 6MV non-MR linac irradiation (R2 =0.9991) with a sensitivity of 0.0302(±0.003)cm-1 Gy-1 . Analysis of TG-119 clinical plans using 3D-gamma (3%/3mm, 10% threshold) give passing rates of: HN 99.1%, prostate 98.0%, C-shape 90.8%, and multi-target 98.5%. The TPS agreed with gPENELOPE with a mean gamma passing rate of 98.4±1.5% (2%/2mm) with the z-score distributions following a standard normal distribution. CONCLUSION We demonstrate for the first time that 3D remote dosimetry using both experimental and computational methods is a feasible and reliable approach to commissioning MR-IMRT, which is particularly useful for less specialized clinics in adopting this new treatment modality.

SU‐F‐I‐52: An Approach to Estimate Noise in Patient Image by Computing the Minimal Difference in Neighborhoods

PURPOSE To quantitatively evaluate and compare the accuracy of two advanced methods that can estimate the level of noise per voxel in patient images. These noise estimation methods show promises in: 1) assuring the performance of imaging systems and algorithms, 2) guiding image processing tasks for clinical and research applications, i.e. by optimization of the parameters, and 3) quantifying patient image quality and assisting image quality improvements. METHODS We conducted an experiment of 34 repeated MRI scans (TrueFISP sequence) of a swine head in order to obtain a ground truth noise dataset. Two published noise estimation methods were implemented in this study: 1) Minimal Difference in Neighborhoods (MDiN) and 2) high-pass MDiN. Noise estimation accuracies of two methods were quantitatively measured using the ground truth data and patient MRI images with added Rician noise. RESULTS The experimental results with both swine head images and patient images showed that the MDiN method is more accurate. The high-pass MDiN method is slightly less but still sufficiently accurate. The MDiN method could be obtained within a 90% accuracy when tested on the ground-truth dataset. CONCLUSION We verified the performance of two efficient methods to automatically estimate per voxel noise levels in patient images. Our results suggest that these methods could be confidently used to assist and guide clinical and research applications that require such noise information. Senior Author Dr. Deshan Yang received research funding form ViewRay and Varian.

TH-CD-BRA-06: Magnetic Field Effects On Gafchromic-Film Response in MR-IGRT

PURPOSE To investigate the effects of magnetic fields in radiochromic films (RCF). Magnetokinetic changes may affect crystal orientation and polymerization within active layer of RCF, these effects are investigated in Magnetic Resonance Image-guided Radiotherapy (MR-IGRT). METHODS Gafchromic EBT2 RCF were irradiated in a 30×30×30 cm3 solid water phantom using a ViewRay MRIdian Co-60 MRI guided radiotherapy system (B=0.35 T). Fifteen 20.3×25.4 cm2 EBT2 film sheets were placed at three different depths (d=0.5, 5 and 10 cm) and irradiated using 5 different treatment plans. The plans were computed using the MRIdian treatment planning system to deliver 2, 4, 6, 8, and 10 Gy at a depth of 10 cm. The films were scanned using an Epson Expression 10000 XL flat-bed document scanner in transmission mode. Films were processed before and after irradiation to obtain a net optical density (netOD) for each color channel separately. Scanning electron microscope (SEM) images were obtained to compare the active layer of selected samples. RESULTS The results show the red channel netOD decreases between 1.3-12.3 % (average of 5.95 %) for doses above 2.8 Gy, with a linear increase in this effect for higher doses. Green channel netOD showed similar results with a decrease between 1.2-10.5 % (average of 4.09 %) for doses above 3.5 Gy. Blue channel showed the weakest effect between 1.3-2.9 % (average of 1.94 %) for doses above 8.0 Gy. SEM images show changes in crystal orientation within active layer in RCF exposed in a magnetic field. CONCLUSION The presence of a magnetic field affects crystal orientation and polymerization during irradiation, decreasing netOD by an average of 5.95 % in the red channel. The under response is dependent on dose and differs by up to 12.3 % at 17.6 Gy. The results show that magnetokinetic effects should be carefully considered in MR-IGRT.

TH-AB-BRA-06: MOSFET-Based Dosimetry in An MR Image-Guided Radiation Therapy System: Comparison with and Without a Static 0.3T Magnetic Field

PURPOSE To compare depth-dose and surface-dose measurements without and with the magnetic field in a 0.3T MR image-guided Co-60 treatment unit using MOSFET dosimeters. METHODS MOSFET dosimeters (Best Medical Canada, model TN-502RDH-10) were placed in a solid water phantom at 5cm depth with 8cm backscatter (with the MOSFET wires in different orientations to the couch long axis) and also on the surface of an 8cm solid water phantom. The phantoms were placed in an MR image-guided Co-60 treatment machine at an SAD of 105cm to the MOSFETs. Dose measurements were performed between 50 and 200cGy at 5cm depth in a 10.5cm × 10.5cm radiation field without the magnetic field (during a machine maintenance period) and with the nominal magnetic field of 0.3T. The dose linearity was measured at 5cm depth with an orthogonal field and the angular dose dependence was measured on the surface with an orthogonal field and oblique fields at +60 degrees and -60 degrees. RESULTS The measured MOSFET readings at 5cm depth were linear with dose with slopes of (2.97 +/- 0.01) mV/cGy and (3.01 +/- 0.02) mV/cGy without and with the magnetic field, respectively. No statistically significant difference was found. The surface dose measurements, however, were lower by 6.4% for the AP field (2.3 σ) with magnetic field, 4.9% for the -60 degree field (1.4 σ), and 0.4% different for the +60 degree field (0.2 σ). CONCLUSION There is no statistically significant difference in the dose at depth without and with the magnetic field and different orientations of the MOSFET wires. There is a statistically significant difference for the surface dose due to the influence of the magnetic field on secondary electrons from head-scatter and the build-up region in certain field orientations. Clinical surface-dose dosimetry in a magnetic field should apply asymmetric angle-dependent corrections.