Emily Heath

Special report: Workshop on 4D-treatment planning in actively scanned particle therapy—Recommendations, technical challenges, and future research directions

This article reports on a 4D-treatment planning workshop (4DTPW), held on 7-8 December 2009 at the Paul Scherrer Institut (PSI) in Villigen, Switzerland. The participants were all members of institutions actively involved in particle therapy delivery and research. The purpose of the 4DTPW was to discuss current approaches, challenges, and future research directions in 4D-treatment planning in the context of actively scanned particle radiotherapy. Key aspects were addressed in plenary sessions, in which leaders of the field summarized the state-of-the-art. Each plenary session was followed by an extensive discussion. As a result, this article presents a summary of recommendations for the treatment of mobile targets (intrafractional changes) with actively scanned particles and a list of requirements to elaborate and apply these guidelines clinically.

Incorporating uncertainties in respiratory motion into 4D treatment plan optimization

The purpose of this work is to investigate robust 4D optimization techniques which account for respiratory motion uncertainties. Two robust optimization techniques were applied to generate 4D optimized lung treatment plans. The probabilistic optimization approach minimizes the dose variance in the target volume while the worst case optimization minimizes a weighted combination of the nominal and worst case dose distributions which occur in the presence of respiratory motion variation. The two 4D optimization approaches were compared with a margin-based midventilation planning approach in five lung patients. Respiratory motion amplitude and baseline variations were quantified from tidal volume measurements during planning 4D CT acquisition. A similar target coverage was obtained for all three approaches, although the 4D optimization methods tended to be better at sparing the organs at risk. Both robust planning methods are suited for automatic determination of treatment plans which ensure target dose conformality under respiratory motion variations, while minimizing the dose burden of healthy lung tissue.

Techniques for adaptive prostate radiotherapy.

Variations in the position and shape of the prostate make accurate setup and treatment challenging. Adaptive radiation therapy (ART) techniques seek to alter the treatment plan, at one or more points throughout the treatment course, in response to changes in patient anatomy observed between planning and pre-treatment images. This article reviews existing and developing ART techniques for prostate cancer along with an overview of supporting in-room imaging technologies. Challenges to the clinical implementation of adaptive radiotherapy are also discussed.

RECORDS: improved Reporting of montE CarlO RaDiation transport Studies: Report of the AAPM Research Committee Task Group 268

Studies involving Monte Carlo simulations are common in both diagnostic and therapy medical physics research, as well as other fields of basic and applied science. As with all experimental studies, the conditions and parameters used for Monte Carlo simulations impact their scope, validity, limitations, and generalizability. Unfortunately, many published peer-reviewed articles involving Monte Carlo simulations do not provide the level of detail needed for the reader to be able to properly assess the quality of the simulations. The American Association of Physicists in Medicine Task Group #268 developed guidelines to improve reporting of Monte Carlo studies in medical physics research. By following these guidelines, manuscripts submitted for peer-review will include a level of relevant detail that will increase the transparency, the ability to reproduce results, and the overall scientific value of these studies. The guidelines include a checklist of the items that should be included in the Methods, Results, and Discussion sections of manuscripts submitted for peer-review. These guidelines do not attempt to replace the journal reviewer, but rather to be a tool during the writing and review process. Given the varied nature of Monte Carlo studies, it is up to the authors and the reviewers to use this checklist appropriately, being conscious of how the different items apply to each particular scenario. It is envisioned that this list will be useful both for authors and for reviewers, to help ensure the adequate description of Monte Carlo studies in the medical physics literature.

Experimental verification of 4D Monte Carlo simulations of dose delivery to a moving anatomy

Purpose: To evaluate a novel 4D Monte Carlo simulation tool by comparing calculations to physical measurements using a respiratory motion phantom. Methods: We used a dynamic Quasar phantom in both stationary and breathing states (sinusoidal motion of amplitude of 1.8 cm and period of 3.3 s) for dose measurements on an Elekta Agility linear accelerator. Gafchromic EBT3 film and the RADPOS 4D dosimetry system were placed inside the lung insert of the phantom to measure dose profiles and point‐dose values at the center of the spherical tumor inside the insert. Both a static 4 × 4 cm2 field and a VMAT plan were delivered. Static and 4D Monte Carlo simulations of the treatment deliveries were performed using DOSXYZnrc and a modified version of the defDOSXYZnrc user code that allows modeling of the continuous motion of both machine and patient. DICOM treatment plan files and linac delivery log files were used to generate corresponding input files. The phantom motion recorded by RADPOS during beam delivery was incorporated into the input files for the 4DdefDOSXYZnrc simulations. Results: For stationary phantom simulations, all point‐dose values from MC simulations at the tumor center agreed within 1% with film and within 2% with RADPOS. More than 98% of the voxels from simulated dose profiles passed a 1D gamma of 2%/2‐mm criteria against measured dose profiles. Similar results were observed when applying a 2D gamma analysis with a 2%/2‐mm criteria to compare 2D dose distributions of Monte Carlo simulations against measurements. For simulations on the moving phantom, MC‐calculated dose values at the center of the tumor were found to be within 1% of film and within 2σ of experimental uncertainties which are 2.8% of the RADPOS measurements. 1D gamma comparisons of the dose profiles were better than 91%, and 2D gamma comparisons of the 2D dose distributions were found to be better than 94%. Conclusion: Our 4D Monte Carlo method using defDOSXYZnrc can be used to accurately calculate the dose distribution in continuously moving anatomy for various treatment techniques. This work, if extended to deformable anatomies, can be used to reconstruct patient delivered dose for use in adaptive radiation therapy.

SU-E-T-627: Precision Modelling of the Leaf-Bank Rotation in Elekta’s Agility MLC: Is It Necessary?

Purpose: To demonstrate the method used to determine the leaf bank rotation angle (LBROT) as a parameter for modeling the Elekta Agility multi-leaf collimator (MLC) for Monte Carlo simulations and to evaluate the clinical impact of LBROT. Methods: A detailed model of an Elekta Infinity linac including an Agility MLC was built using the EGSnrc/BEAMnrc Monte Carlo code. The Agility 160-leaf MLC is modelled using the MLCE component module which allows for leaf bank rotation using the parameter LBROT. A precise value of LBROT is obtained by comparing measured and simulated profiles of a specific field, which has leaves arranged in a repeated pattern such that one leaf is opened and the adjacent one is closed. Profile measurements from an Agility linac are taken with gafchromic film, and an ion chamber is used to set the absolute dose. The measurements are compared to Monte Carlo (MC) simulations and the LBROT is adjusted until a match is found. The clinical impact of LBROT is evaluated by observing how an MC dose calculation changes with LBROT. A clinical Stereotactic Body Radiation Treatment (SBRT) plan is calculated using BEAMnrc/DOSXYZnrc simulations with different input values for LBROT. Results: Using the method outlined above, the LBROT is determined to be 9±1 mrad. Differences as high as 4% are observed in a clinical SBRT plan between the extreme case (LBROT not modeled) and the nominal case. Conclusion: In small-field radiation therapy treatment planning, it is important to properly account for LBROT as an input parameter for MC dose calculations with the Agility MLC. More work is ongoing to elucidate the observed differences by determining the contributions from transmission dose, change in field size, and source occlusion, which are all dependent on LBROT. This work was supported by OCAIRO (Ontario Consortium of Adaptive Interventions in Radiation Oncology), funded by the Ontario Research Fund.

Automated four-dimensional Monte Carlo workflow using log files and real-time motion monitoring

With emerging techniques for tracking and gating methods in radiotherapy of lung cancer patients, there is an increasing need for efficient four-dimensional Monte Carlo (4DMC) based quality assurance (QA). An automated and flexible workflow for 4DMC QA, based on the 4DdefDOSXYZnrc user code, has been developed in python. The workflow has been tested and verified using an in-house developed dosimetry system comprised of a dynamic thorax phantom constructed for plastic scintillator dosimetry. The workflow is directly compatible with any treatment planning system and can also be triggered by the appearance of linac log files. It has minimum user interaction and, with the use of linac log files, it provides a method for verification of the actually delivered dose in the patient geometry.

Robustness assessment of a novel IMRT planning method for lung radiotherapy.

PURPOSE Conventional radiotherapy treatment planning for lung cancer accounts for tumour motion by increasing the beam apertures. We recently developed an IMRT planning strategy which uses reduced beam apertures in combination with an edge enhancing boost to compensate for loss of coverage due to respiration. Previous results showed that this approach ensures target coverage while reducing lung dose. The current study evaluated the robustness of this boost volume (BV) technique to changes in respiratory motion, including amplitude and time spent in each respiratory phase. METHODS ITV and BV plans were generated for one NSCLC patient with respiratory motion amplitude of 0.9cm. Dose was accumulated for three different weightings of the 4DCT phases. Nine numerical phantoms were created with tumour sizes of 3cm, 5cm and 6.5cm and motion amplitudes of 7mm, 10mm and 14mm. The robustness of BV and ITV plans to variations in motion amplitude was assessed. The relative contributions of the width of the boost volume and the boost dose to plans efficacy and robustness were investigated. RESULTS The BV plans were robust to typical variations in the time spent at each respiratory phase. Both ITV and BV plans were robust to 3mm amplitude decreases but not to 3mm amplitude increases. Increasing the boost dose from 110% to 120% of the prescription dose had negligible effect in improving tumour coverage. CONCLUSION To improve the robustness of this technique the width of the boost volume needs to be increased.

Development of a deformable phantom for experimental verification of 4D Monte Carlo simulations in a deforming anatomy

PURPOSE To verify the accuracy of 4D Monte Carlo (MC) simulations, using the 4DdefDOSXYZnrc user code, in a deforming anatomy. We developed a tissue-equivalent and reproducible deformable lung phantom and evaluated 4D simulations of delivered dose to the phantom by comparing calculations against measurements. METHODS A novel deformable phantom consisting of flexible foam, emulating lung tissue, inside a Lucite external body was constructed. A removable plug, containing an elastic tumor that can hold film and other dosimeters, was inserted in the phantom. Point dose and position measurements were performed inside and outside the tumor using RADPOS 4D dosimetry system. The phantom was irradiated on an Elekta Infinity linac in both stationary and moving states. The dose delivery was simulated using delivery log files and the phantom motion recorded with RADPOS. RESULTS Reproducibility of the phantom motion was determined to be within 1 mm. The phantom motion presented realistic features like hysteresis. MC calculations and measurements agreed within 2% at the center of tumor. Outside the tumor agreements were better than 5% which were within the positional/dose reading uncertainties at the measurement points. More than 94% of dose points from MC simulations agreed within 2%/2 mm compared to film measurements. CONCLUSION The deformable lung phantom presented realistic and reproducible motion characteristics and its use for verification of 4D dose calculations was demonstrated. Our 4DMC method is capable of accurate calculations of the realistic dose delivered to a moving and deforming anatomy during static and dynamic beam delivery techniques.

RECORDS: improved reporting of Monte Carlo radiation transport studies

Studies involving Monte Carlo simulations are common in both diagnostic and therapy medical phy- sics research, as well as other fields of basic and applied science. As with all experimental studies , the conditions and parameters used for Monte Carlo simulations impact their scope, validity, limita- tions, and generalizability. Unfortunately, many published peer-reviewed articles involving Mont e Carlo simulations do not provide the level of detail needed for the reader to be able to properly assess the quality of the simulations. The American Association of Physicists in Medicine Task Group #268 developed guidelines to improve reporting of Monte Carlo studies in medical physics research. By following these guidelines, manuscripts submitted for peer-review will include a level of relevant detail that will increase the transparency, the ability to reproduce results, and the overall scientific value of these studies. The guidelines include a checklist of the items that should be included in the Methods, Results, and Discussion sections of manuscripts submitted for peer-review. These guideli- nes do not attempt to replace the journal reviewer, but rather to be a tool during the writing and review process. Given the varied nature of Monte Carlo studies, it is up to the authors and the review- ers to use this checklist appropriately, being conscious of how the different items apply to each partic- ular scenario. It is envisioned that this list will be useful both for authors and for reviewers, to help ensure the adequate description of Monte Carlo studies in the medical physics literatur.