B Norrlinger

Patient dose from kilovoltage cone beam computed tomography imaging in radiation therapy

Kilovoltage cone-beam computerized tomography (kV-CBCT) systems integrated into the gantry of linear accelerators can be used to acquire high-resolution volumetric images of the patient in the treatment position. Using on-line software and hardware, patient position can be determined accurately with a high degree of precision and, subsequently, set-up parameters can be adjusted to deliver the intended treatment. While the patient dose due to a single volumetric imaging acquisition is small compared to the therapy dose, repeated and daily image guidance procedures can lead to substantial dose to normal tissue. The dosimetric properties of a clinical CBCT system have been studied on an Elekta linear accelerator (Synergy RP, XVI system) and additional measurements performed on a laboratory system with identical geometry. Dose measurements were performed with an ion chamber and MOSFET detectors at the center, periphery, and surface of 30 and 16-cm-diam cylindrical shaped water phantoms, as a function of x-ray energy and longitudinal field-of-view (FOV) settings of 5,10,15, and 26 cm. The measurements were performed for full 360 degrees CBCT acquisition as well as for half-rotation scans for 120 kVp beams using the 30-cm-diam phantom. The dose at the center and surface of the body phantom were determined to be 1.6 and 2.3 cGy for a typical imaging protocol, using full rotation scan, with a technique setting of 120 kVp and 660 mAs. The results of our measurements have been presented in terms of a dose conversion factor fCBCT, expressed in cGy/R. These factors depend on beam quality and phantom size as well as on scan geometry and can be utilized to estimate dose for any arbitrary mAs setting and reference exposure rate of the x-ray tube at standard distance. The results demonstrate the opportunity to manipulate the scanning parameters to reduce the dose to the patient by employing lower energy (kVp) beams, smaller FOV, or by using half-rotation scan.

An integral quality monitoring system for real‐time verification of intensity modulated radiation therapy

PURPOSE To develop an independent and on-line beam monitoring system, which can validate the accuracy of segment-by-segment energy fluence delivery for each treatment field. The system is also intended to be utilized for pretreatment dosimetric quality assurance of intensity modulated radiation therapy (IMRT), on-line image-guided adaptive radiation therapy, and volumetric modulated arc therapy. METHODS The system, referred to as the integral quality monitor (IQM), utilizes an area integrating energy fluence monitoring sensor (AIMS) positioned between the final beam shaping device [i.e., multileaf collimator (MLC)] and the patient. The prototype AIMS consists of a novel spatially sensitive large area ionization chamber with a gradient along the direction of the MLC motion. The signal from the AIMS provides a simple output for each beam segment, which is compared in real time to the expected value. The prototype ionization chamber, with a physical area of 22 x 22 cm2, has been constructed out of aluminum with the electrode separations varying linearly from 2 to 20 mm. A calculation method has been developed to predict AIMS signals based on an elementwise integration technique, which takes into account various predetermined factors, including the spatial response function of the chamber, MLC characteristics, beam transmission through the secondary jaws, and field size factors. The influence of the ionization chamber on the beam has been evaluated in terms of transmission, surface dose, beam profiles, and depth dose. The sensitivity of the system was tested by introducing small deviations in leaf positions. A small set of IMRT fields for prostate and head and neck plans was used to evaluate the system. The ionization chamber and the data acquisition software systems were interfaced to two different types of linear accelerators: Elekta Synergy and Varian iX. RESULTS For a 10 x 10 cm2 field, the chamber attenuates the beam intensity by 7% and 5% for 6 and 18 MV beams, respectively, without significantly changing the depth dose, surface dose, and dose profile characteristics. An MLC bank calibration error of 1 mm causes the IQM signal of a 3 x 3 cm2 aperture to change by 3%. A positioning error in a single 5 mm wide leaf by 3 mm in 3 X 3 cm2 aperture causes a signal difference of 2%. Initial results for prostate and head and neck IMRT fields show an average agreement between calculation and measurement to within 1%, with a maximum deviation for each of the smallest beam segments to within 5%. When the beam segments of a prostate IMRT field were shifted by 3 mm from their original position, along the direction of the MLC motion, the IQM signals varied, on average, by 2.5%. CONCLUSIONS The prototype IQM system can validate the accuracy of beam delivery in real time by comparing precalculated and measured AIMS signals. The system is capable of capturing errors in MLC leaf calibration or malfunctions in the positioning of an individual leaf. The AIMS does not significantly alter the beam quality and therefore could be implemented without requiring recommissioning measurements.

Evaluation of the effect of patient dose from cone beam computed tomography on prostate IMRT using Monte Carlo simulation

The aim of this study is to evaluate the impact of the patient dose due to the kilovoltage cone beam computed tomography (kV-CBCT) in a prostate intensity-modulated radiation therapy (IMRT). The dose distributions for the five prostate IMRTs were calculated using the Pinnacle treatment planning system. To calculate the patient dose from CBCT, phase-space beams of a CBCT head based on the ELEKTA x-ray volume imaging system were generated using the Monte Carlo BEAMnr code for 100, 120, 130, and 140 kVp energies. An in-house graphical user interface called DOSCTP (DOSXYZnrc-based) developed using MATLAB was used to calculate the dose distributions due to a 360 degrees photon arc from the CBCT beam with the same patient CT image sets as used in Pinnacle. The two calculated dose distributions were added together by setting the CBCT doses equal to 1%, 1.5%, 2%, and 2.5% of the prescription dose of the prostate IMRT. The prostate plan and the summed dose distributions were then processed in the CERR platform to determine the dose-volume histograms (DVHs) of the regions of interest. Moreover, dose profiles along the x- and y-axes crossing the isocenter with and without addition of the CBCT dose were determined. It was found that the added doses due to CBCT are most significant at the femur heads. Higher doses were found at the bones for a relatively low energy CBCT beam such as 100 kVp. Apart from the bones, the CBCT dose was observed to be most concentrated on the anterior and posterior side of the patient anatomy. Analysis of the DVHs for the prostate and other critical tissues showed that they vary only slightly with the added CBCT dose at different beam energies. On the other hand, the changes of the DVHs for the femur heads due to the CBCT dose and beam energy were more significant than those of rectal and bladder wall. By analyzing the vertical and horizontal dose profiles crossing the femur heads and isocenter, with and without the CBCT dose equal to 2% of the prescribed dose, it was found that there is about a 5% increase of dose at the femur head. Still, such an increase in the femur head dose is well below the dose limit of the bone in our IMRT plans. Therefore, under these dose fractionation conditions, it is concluded that, though CBCT causes a higher dose deposited at the bones, there may be no significant effect in the DVHs of critical tissues in the prostate IMRT.

A novel four-dimensional radiotherapy method for lung cancer: imaging, treatment planning and delivery.

We present treatment planning methods based on four-dimensional computed tomography (4D-CT) to incorporate tumour motion using (1) a static field and (2) a dynamic field. Static 4D fields are determined to include the target in all breathing phases, whereas dynamic 4D fields are determined to follow the shape of the tumour assessed from 4D-CT images with a dynamic weighting factor. The weighting factor selection depends on the reliability of patient breathing and limitations of the delivery system. The static 4D method is compared with our standard protocol for gross tumour volume (GTV) coverage, mean lung dose and V20. It was found that the GTV delineated on helical CT without incorporating breathing motion does not adequately represent the target compared to the GTV delineated from 4D-CT. Dosimetric analysis indicates that the static 4D-CT based technique results in a reduction of the mean lung dose compared with the standard protocol. Measurements on a moving phantom and simulations indicated that 4D radiotherapy (4D-RT) synchronized with respiration-induced motion further reduces mean lung dose and V20, and may allow safe application of dose escalation and CRT/IMRT. The motions of the chest cavity, tumour and thoracic structures of 24 lung cancer patients are also analysed.

A method for online verification of adapted fields using an independent dose monitor

PURPOSE Clinical implementation of online adaptive radiotherapy requires generation of modified fields and a method of dosimetric verification in a short time. We present a method of treatment field modification to account for patient setup error, and an online method of verification using an independent monitoring system. METHODS The fields are modified by translating each multileaf collimator (MLC) defined aperture in the direction of the patient setup error, and magnifying to account for distance variation to the marked isocentre. A modified version of a previously reported online beam monitoring system, the integral quality monitoring (IQM) system, was investigated for validation of adapted fields. The system consists of a large area ion-chamber with a spatial gradient in electrode separation to provide a spatially sensitive signal for each beam segment, mounted below the MLC, and a calculation algorithm to predict the signal. IMRT plans of ten prostate patients have been modified in response to six randomly chosen setup errors in three orthogonal directions. RESULTS A total of approximately 49 beams for the modified fields were verified by the IQM system, of which 97% of measured IQM signal agree with the predicted value to within 2%. CONCLUSIONS The modified IQM system was found to be suitable for online verification of adapted treatment fields.

Multileaf collimator performance monitoring and improvement using semiautomated quality control testing and statistical process control

PURPOSE High-quality radiation therapy using highly conformal dose distributions and image-guided techniques requires optimum machine delivery performance. In this work, a monitoring system for multileaf collimator (MLC) performance, integrating semiautomated MLC quality control (QC) tests and statistical process control tools, was developed. The MLC performance monitoring system was used for almost a year on two commercially available MLC models. Control charts were used to establish MLC performance and assess test frequency required to achieve a given level of performance. MLC-related interlocks and servicing events were recorded during the monitoring period and were investigated as indicators of MLC performance variations. METHODS The QC test developed as part of the MLC performance monitoring system uses 2D megavoltage images (acquired using an electronic portal imaging device) of 23 fields to determine the location of the leaves with respect to the radiation isocenter. The precision of the MLC performance monitoring QC test and the MLC itself was assessed by detecting the MLC leaf positions on 127 megavoltage images of a static field. After initial calibration, the MLC performance monitoring QC test was performed 3-4 times/week over a period of 10-11 months to monitor positional accuracy of individual leaves for two different MLC models. Analysis of test results was performed using individuals control charts per leaf with control limits computed based on the measurements as well as two sets of specifications of ± 0.5 and ± 1 mm. Out-of-specification and out-of-control leaves were automatically flagged by the monitoring system and reviewed monthly by physicists. MLC-related interlocks reported by the linear accelerator and servicing events were recorded to help identify potential causes of nonrandom MLC leaf positioning variations. RESULTS The precision of the MLC performance monitoring QC test and the MLC itself was within ± 0.22 mm for most MLC leaves and the majority of the apparent leaf motion was attributed to beam spot displacements between irradiations. The MLC QC test was performed 193 and 162 times over the monitoring period for the studied units and recalibration had to be repeated up to three times on one of these units. For both units, rate of MLC interlocks was moderately associated with MLC servicing events. The strongest association with the MLC performance was observed between the MLC servicing events and the total number of out-of-control leaves. The average elapsed time for which the number of out-of-specification or out-of-control leaves was within a given performance threshold was computed and used to assess adequacy of MLC test frequency. CONCLUSIONS A MLC performance monitoring system has been developed and implemented to acquire high-quality QC data at high frequency. This is enabled by the relatively short acquisition time for the images and automatic image analysis. The monitoring system was also used to record and track the rate of MLC-related interlocks and servicing events. MLC performances for two commercially available MLC models have been assessed and the results support monthly test frequency for widely accepted ± 1 mm specifications. Higher QC test frequency is however required to maintain tighter specification and in-control behavior.

Quality assurance of electron beams using a Varian electronic portal imaging device

The feasibility of utilizing an electronic portal imaging device (EPID) for the quality assurance of electron beams was investigated. This work was conducted on a Varian 2100iX machine equipped with an amorphous silicon (aS1000) portal imager. The linearity of the imager pixel response as a function of exposed dose was first confirmed. The short-term reproducibility of the EPID response to electron beams was verified. Low (6 MeV), medium (12 MeV) and high (20 MeV) energies were tested, each along with small (6 × 6 cm(2)), medium (10 × 10 cm(2)) and large (20 × 20 cm(2)) applicators. Acquired EPID images were analyzed using an in-house MATLAB code for radiation field size, penumbra, symmetry and flatness. Field sizes and penumbra values agreed with those from film dosimetry to within 1 mm. Field symmetry and flatness constancies were measured over a period of three weeks. The results indicate that EPID can be used for routine quality assurance of electron beams.

SU‐GG‐T‐305: Feasibility of Using a Programmable Respiratory Motion Phantom for QA and Assessment of Dosimetric Implications of Breathing Motion During Radiation Therapy

Purpose: Respiratory motion introduces uncertainties during CT and radiation therapydelivery. Reliable equipment and quality assurance (QA) techniques must be established to assess and overcome these uncertainties. Our goal was to validate the performance of a programmable motion phantom for QA and to demonstrate the dosimetric impact of breathing motion on treatmentdelivery.Method and Materials: The “Quasar” phantom (Modus Medical, London, ON) was assessed for suitability in QA procedures for radiation therapy involving respiratory motion. The phantom is equipped with a programmable unit, which introduces motion to cylindrical lung inserts. We tested the standard mode of motion and the “oscillation” mode, in which patient breathing profiles are imported and reproduced. Phantom motion reproducibility and accuracy were assessed using the Varian Real‐time Position Management (RPM) system and video for the extreme breathing periods (1 and 15seconds) and a patient representative breathing period of 4seconds. An in‐house designed cedar lung insert was built containing a target (4cm by 7cm). Film is placed in the insert to assess the dose distribution under phantom motion from static and dynamic delivery under phantom motion. The dynamic MLCtreatmentdelivery was synchronized with target motion. Results: Using the RPM system, percent differences between the intended and actual periods for each were 0.57%, −1.70% and −0.22% respectively. When the amplitude was changed from 2cm to 1cm, the measured period did not change. Comparison of the breathing profiles in oscillation mode with profiles generated using the RPM system shows a close correspondence, with slight divergence at extreme direction or speed variation. Dose distribution for a phantom motion of 2cm peak‐to‐peak and period of 3.2sec along the moving direction indicates significant broadening of (80–20%) penumbra for static delivery (1.67cm) compared to dynamic delivery (0.80cm) Conclusion: The Quasar phantom is suitable for QA and dosimetric measurements of moving targets.

SU-E-T-160: Characterization and Monitoring of Linear Accelerator Gantry Radiation Isocenter Motion

Purpose: To characterize the motion of the radiation isocenter, over time, as a function of gantry rotation for multiple linear accelerators (linacs). Two semi-automated image-based quality control (QC) test workflows were designed to achieve this goal. Methods: The full QC-test workflow for motion characterization consisted of acquiring 16 megavoltage images at 8 gantry angles of a ball-bearing suspended off the end of the couch. Performance constancy was assessed using a shortened QC-test workflow which consisted of imaging a cube phantom placed on the couch (5 images at 4 gantry angles). Both workflows use an image processing algorithm to determine the field center and phantom position on each image and computed radiation isocenter motion as a function of gantry angle. Motion was characterized for 9 linacs of same model and performance monitored for 2 months on 3 linacs. Results: The maximum isocenter motion determined with the full-workflow for 9 linacs was within 0.38–0.79 mm. The shortened-workflow usually agreed within 0.1 mm with the full-workflow and the time required for these methods was about 4 and 15 min, respectively. For all linacs, the isocenter motion perpendicular to the gantry rotation plane followed a consistent pattern with maximum amplitude of 0.36–0.59 mm. In the gantry rotation plane, the variation among linacs was higher and the beam axis described a circle of up to 0.6 mm radius around the gantry axis of rotation (2 linacs). The radiation isocenter motion was stable as a function of time for the monitored linacs and was within ±0.1 mm of the average. Conclusion: Radiation isocenter motion parallel and perpendicular to the gantry rotation plane was characterized. In the gantry rotation plane, beam spot positioning adjustment might be used to reduce the observed radiation isocenter motion. A shortened-workflow was designed and enables performance monitoring over time.

SU‐E‐T‐94: Multileaf Collimator Performance and Validation of Quality Control Tolerances

PURPOSE The automated quality assurance system (AQUA) is a centralized quality control (QC) software designed to automate QC tests. Statistical analysis of AQUA results was performed to assess the geometric accuracy and long-term reproducibility of a commercially available multileaf collimator (MLC) and examine the applicability of the American Association of Physicists in Medicine (AAPM) tolerances for MLC QC. METHODS The MLC was first calibrated with AQUA by minimizing leaf-positioning errors on megavoltage images for 5 different leaf-bank positions (-60 to 100 mm from radiation isocenter). Leaf-positioning accuracy and reproducibility was assessed by repeating the AQUA test 5 times/week. The range of leaf-positioning error over leaf-bank positions and time was reported. Measured leaf-positioning errors were then separated into systematic and random error components. The systematic error corresponds to the variation (standard deviation) in mean positioning errors between leaves over leaf-bank positions and time. The random error quantifies the leaf position variations around its mean and is calculated as the root-mean-square of the individual leaf position standard deviations. RESULTS To date, 2 different MLCs have been calibrated using AQUA and 9-18 datasets have been acquired to assess performance. For the unit with the longest follow up, the range of leaf-positioning errors was -0.62 to 0.85 mm and 98% of the measured leaf positions (n=7200) were within ±0.5 mm of the nominal position. The systematic error was the main error component (±0.15 to ±0.2 mm) and was attributed to the residual errors after calibration. The random error was ±0.07 mm for both units and demonstrated good leaf-positioning reproducibility and limited uncertainty of the AQUA measurements. CONCLUSIONS Preliminary results show that after MLC calibration with AQUA, leaf-positioning errors on two different units are well within the AAPM-recommended ±1 mm tolerances. Additional MLC performance improvement is possible if residual errors after calibration can be reduced further as the MLC demonstrated high reproducibility. Funded in part by Elekta Inc.