J Siebers

Insight gained from responses to surveys on reference dosimetry practices

Purpose To present the results and discuss potential insights gained through surveys on reference dosimetry practices. Methods Two surveys were sent to medical physicists to learn about the current state of reference dosimetry practices at radiation oncology clinics worldwide. A short survey designed to maximize response rate was made publicly available and distributed via the AAPM website and a medical physics list server. Another, much more involved survey, was sent to a smaller group of physicists to gain insight on detailed dosimetry practices. The questions were diverse, covering reference dosimetry practices on topics like measurements required for beam quality specification, the actual measurement of absorbed dose and ancillary equipment required like electrometers and environment monitoring measurements. Results There were 190 respondents to the short survey and seven respondents to the detailed survey. The diversity of responses indicates nonuniformity in reference dosimetry practices and differences in interpretation of reference dosimetry protocols. Conclusions The results of these surveys offer insight on clinical reference dosimetry practices and will be useful in identifying current and future needs for reference dosimetry.

A Swiss cheese error detection method for real-time EPID-based quality assurance and error prevention

Purpose To develop a robust and efficient process that detects relevant dose errors (dose errors of ≥5%) in external beam radiation therapy and directly indicates the origin of the error. The process is illustrated in the context of electronic portal imaging device (EPID)‐based angle‐resolved volumetric‐modulated arc therapy (VMAT) quality assurance (QA), particularly as would be implemented in a real‐time monitoring program. Methods A Swiss cheese error detection (SCED) method was created as a paradigm for a cine EPID‐based during‐treatment QA. For VMAT, the method compares a treatment plan‐based reference set of EPID images with images acquired over each 2° gantry angle interval. The process utilizes a sequence of independent consecutively executed error detection tests: an aperture check that verifies in‐field radiation delivery and ensures no out‐of‐field radiation; output normalization checks at two different stages; global image alignment check to examine if rotation, scaling, and translation are within tolerances; pixel intensity check containing the standard gamma evaluation (3%, 3 mm) and pixel intensity deviation checks including and excluding high dose gradient regions. Tolerances for each check were determined. To test the SCED method, 12 different types of errors were selected to modify the original plan. A series of angle‐resolved predicted EPID images were artificially generated for each test case, resulting in a sequence of precalculated frames for each modified treatment plan. The SCED method was applied multiple times for each test case to assess the ability to detect introduced plan variations. To compare the performance of the SCED process with that of a standard gamma analysis, both error detection methods were applied to the generated test cases with realistic noise variations. Results Averaged over ten test runs, 95.1% of all plan variations that resulted in relevant patient dose errors were detected within 2° and 100% within 14° (<4% of patient dose delivery). Including cases that led to slightly modified but clinically equivalent plans, 89.1% were detected by the SCED method within 2°. Based on the type of check that detected the error, determination of error sources was achieved. With noise ranging from no random noise to four times the established noise value, the averaged relevant dose error detection rate of the SCED method was between 94.0% and 95.8% and that of gamma between 82.8% and 89.8%. Conclusions An EPID‐frame‐based error detection process for VMAT deliveries was successfully designed and tested via simulations. The SCED method was inspected for robustness with realistic noise variations, demonstrating that it has the potential to detect a large majority of relevant dose errors. Compared to a typical (3%, 3 mm) gamma analysis, the SCED method produced a higher detection rate for all introduced dose errors, identified errors in an earlier stage, displayed a higher robustness to noise variations, and indicated the error source.

SU-F-T-469: A Clinically Observed Discrepancy Between Image-Based and Log- Based MLC Position

PURPOSEnTo present a clinical case which challenges the base assumption of log-file based QA, by showing that the actual position of a MLC leaf can suddenly deviate from its programmed and logged position by >1 mm as observed with real-time imaging.nnnMETHODSnAn EPID-based exit-fluence dosimetry system designed to prevent gross delivery errors was used in cine mode to capture portal images during treatment. Visual monitoring identified an anomalous MLC leaf pair gap not otherwise detected by the automatic position verification. The position of the erred leaf was measured on EPID images and log files were analyzed for the treatment in question, the prior days treatment, and for daily MLC test patterns acquired on those treatment days. Additional standard test patterns were used to quantify the leaf position.nnnRESULTSnWhereas the log file reported no difference between planned and recorded positions, image-based measurements showed the leaf to be 1.3±0.1 mm medial from the planned position. This offset was confirmed with the test pattern irradiations.nnnCONCLUSIONnIt has been clinically observed that log-file derived leaf positions can differ from their actual positions by >1 mm, and therefore cannot be considered to be the actual leaf positions. This cautions the use of log-based methods for MLC or patient quality assurance without independent confirmation of log integrity. Frequent verification of MLC positions through independent means is a necessary precondition to trusting log file records. Intra-treatment EPID imaging provides a method to capture departures from MLC planned positions. Work was supported in part by Varian Medical Systems.

SU-F-T-258: Efficacy of Exit Fluence-Based Dose Calculation for Prostate Radiation Therapy

PURPOSEnTo investigate the efficacy of exit-fluence-based dose computation for prostate radiotherapy by determining if it estimates true dose more accurately than the original planning dose.nnnMETHODSnVirtual exit-fluencebased dose computation was performed for 19 patients, each with 9-12 repeat CT images. For each patient, a 78 Gy treatment plan was created utilizing 5 mm CTV-to-PTV and OAR-to-PRV margins. A Monte Carlo framework was used to compute dose and exit-fluence images for the planning image and for each repeat CT image based on boney-anatomyaligned and prostate-centroid-aligned CTs. Identical source particles were used for the MC dose-computations on the planning and repeat CTs to maximize correlation. The exit-fluence-based dose and image were computed by multiplying source particle weights by FC(x,y)=FP(x,y)/FT(x,y), where (x,y) are the source particle coordinates projected to the exit-fluence plane and we denote the dose/fluence from the plan by (DP,FP), from the repeat-CT as (DT,FT), and the exit-fluence computation by (DFC,FFC). DFC mimics exit-fluence backprojection through the planning image as FT=FFC. Dose estimates were intercompared to judge the efficacy of exit-fluence-based dose computation.nnnRESULTSnBoney- and prostate-centroid aligned results are combined as there is no statistical difference between them, yielding 420 dose comparisons per dose-volume metric. DFC is more accurate than DP for 46%, 33%, and 44% of cases in estimating CTV D98, D50, and D2 respectively. DFC improved rectum D50 and D2 estimates 54% and 49% respectively and bladder D50 and D2 47 and 49% respectively. While averaged over all patients and images DFC and DP were within 3.1% of DT, they differed from DT by as much as 22% for GTV D98, 71% for the Bladder D50, 17% for Bladder D2, 19% for Rectum D2.nnnCONCLUSIONnExit-fluence based dose computations infrequently improve CTV or OAR dose estimates and should be used with caution. Research supported in part by Varian Medical Systems.

SU-G-BRB-16: Vulnerabilities in the Gamma Metric

PURPOSEnTo explore vulnerabilities in the gamma index metric that undermine its wide use as a radiation therapy quality assurance tool.nnnMETHODSn2D test field pairs (images) are created specifically to achieve high gamma passing rates, but to also include gross errors by exploiting the distance-to-agreement and percent-passing components of the metric. The first set has no requirement of clinical practicality, but is intended to expose vulnerabilities. The second set exposes clinically realistic vulnerabilities. To circumvent limitations inherent to user-specific tuning of prediction algorithms to match measurements, digital test cases are manually constructed, thereby mimicking high-quality image prediction.nnnRESULTSnWith a 3 mm distance-to-agreement metric, changing field size by ±6 mm results in a gamma passing rate over 99%. For a uniform field, a lattice of passing points spaced 5 mm apart results in a passing rate of 100%. Exploiting the percent-passing component, a 10×10 cm2 field can have a 95% passing rate when an 8 cm2 =2.8×2.8 cm2 highly out-of-tolerance (e.g. zero dose) square is missing from the comparison image. For clinically realistic vulnerabilities, an arc plan for which a 2D image is created can have a >95% passing rate solely due to agreement in the lateral spillage, with the failing 5% in the critical target region. A field with an integrated boost (e.g whole brain plus small metastases) could neglect the metastases entirely, yet still pass with a 95% threshold. All the failure modes described would be visually apparent on a gamma-map image.nnnCONCLUSIONnThe %gamma<1 metric has significant vulnerabilities. High passing rates can obscure critical faults in hypothetical and delivered radiation doses. Great caution should be used with gamma as a QA metric; users should inspect the gamma-map. Visual analysis of gamma-maps may be impractical for cine acquisition.

SU-G-BRC-15: The Potential Clinical Significance of Dose Mapping Error for Intra- Fraction Dose Mapping for Lung Cancer Patients

PURPOSEnTo evaluate the dose-mapping error (DME) inherent to conventional dose-mapping algorithms as a function of dose-matrix resolution.nnnMETHODSnAs DME has been reported to be greatest where dose-gradients overlap tissue-density gradients, non-clinical 66 Gy IMRT plans were generated for 11 lung patients with the target edge defined as the maximum 3D density gradient on the 0% (end of inhale) breathing phase. Post-optimization, Beams were copied to 9 breathing phases. Monte Carlo dose computed (with 2*2*2 mm3 resolution) on all 10 breathing phases was deformably mapped to phase 0% using the Monte Carlo energy-transfer method with congruent mass-mapping (EMCM); an externally implemented tri-linear interpolation method with voxel sub-division; Pinnacles internal (tri-linear) method; and a post-processing energy-mass voxel-warping method (dTransform). All methods used the same base displacement-vector-field (or its pseudo-inverse as appropriate) for the dose mapping. Mapping was also performed at 4*4*4 mm3 by merging adjacent dose voxels.nnnRESULTSnUsing EMCM as the reference standard, no clinically significant (>1 Gy) DMEs were found for the mean lung dose (MLD), lung V20Gy, or esophagus dose-volume indices, although MLD and V20Gy were statistically different (2*2*2 mm3 ). Pinnacle-to-EMCM target D98% DMEs of 4.4 and 1.2 Gy were observed (2*2*2 mm3 ). However dTransform, which like EMCM conserves integral dose, had DME >1 Gy for one case. The root mean square RMS of the DME for the tri-linear-to- EMCM methods was lower for the smaller voxel volume for the tumor 4D-D98%, lung V20Gy, and cord D1%.nnnCONCLUSIONnWhen tissue gradients overlap with dose gradients, organs-at-risk DME was statistically significant but not clinically significant. Target-D98%-DME was deemed clinically significant for 2/11 patients (2*2*2 mm3 ). Since tri-linear RMS-DME between EMCM and tri-linear was reduced at 2*2*2 mm3 , use of this resolution is recommended for dose mapping. Interpolative dose methods are sufficiently accurate for the majority of cases. J.V. Siebers receives funding support from Varian Medical Systems.

MO-FG-202-01: A Fast Yet Sensitive EPID-Based Real-Time Treatment Verification System

PURPOSEnTo create a real-time EPID-based treatment verification system which robustly detects treatment delivery and patient attenuation variations.nnnMETHODSnTreatment plan DICOM files sent to the record-and-verify system are captured and utilized to predict EPID images for each planned control point using a modified GPU-based digitally reconstructed radiograph algorithm which accounts for the patient attenuation, source energy fluence, source size effects, and MLC attenuation. The DICOM and predicted images are utilized by our C++ treatment verification software which compares EPID acquired 1024×768 resolution frames acquired at ∼8.5hz from Varian Truebeam™ system. To maximize detection sensitivity, image comparisons determine (1) if radiation exists outside of the desired treatment field; (2) if radiation is lacking inside the treatment field; (3) if translations, rotations, and magnifications of the image are within tolerance. Acquisition was tested with known test fields and prior patient fields. Error detection was tested in real-time and utilizing images acquired during treatment with another system.nnnRESULTSnThe computational time of the prediction algorithms, for a patient plan with 350 control points and 60×60×42cm^3 CT volume, is 2-3minutes on CPU and <27 seconds on GPU for 1024×768 images. The verification software requires a maximum of ∼9ms and ∼19ms for 512×384 and 1024×768 resolution images, respectively, to perform image analysis and dosimetric validations. Typical variations in geometric parameters between reference and the measured images are 0.32°for gantry rotation, 1.006 for scaling factor, and 0.67mm for translation. For excess out-of-field/missing in-field fluence, with masks extending 1mm (at isocenter) from the detected aperture edge, the average total in-field area missing EPID fluence was 1.5mm2 the out-of-field excess EPID fluence was 8mm^2, both below error tolerances.nnnCONCLUSIONnA real-time verification software, with EPID images prediction algorithm, was developed. The system is capable of performing verifications between frames acquisitions and identifying source(s) of any out-of-tolerance variations. This work was supported in part by Varian Medical Systems.

TU‐D‐201‐03: Results of a Survey On the Implementation of the TG‐51 Protocol and Associated Addendum On Reference Dosimetry of External Beams

PURPOSEnThe working group on the review and extension of the TG-51 protocol (WGTG51) collected data from American Association of Physicists in Medicine (AAPM) members with respect to their current TG-51 and associated addendum usage in the interest of considering future protocol addenda and guidance on reference dosimetry best practices. This study reports an overview of this survey on dosimetry of external beams.nnnMETHODSnFourteen survey questions were developed by WGTG51 and released in November 2015. The questions collected information on reference dosimetry, beam quality specification, and ancillary calibration equipment.nnnRESULTSnOf the 190 submissions completed worldwide (U.S. 70%), 83% were AAPM members. Of the respondents, 33.5% implemented the TG-51 addendum, with the maximum calibration difference for any photon beam, with respect to the original TG-51 protocol, being <1% for 97.4% of responses. One major finding is that 81.8% of respondents used the same cylindrical ionization chamber for photon and electron dosimetry, implying that many clinics are foregoing the use of parallel-plate chambers. Other evidence suggests equivalent dosimetric results can be obtained with both cylindrical and parallel-plate chambers in electron beams. This, combined with users comfort with cylindrical chambers for electrons will likely impact recommendations put forward in an upcoming electron beam addendum to the TG-51 protocol. Data collected on ancillary equipment showed 58.2% (45.0%) of the thermometers (barometers) in use for beam calibration had NIST traceable calibration certificates, but 48.4% (42.7%) were never recalibrated.nnnCONCLUSIONnThis survey provides a snapshot of TG-51 external beam reference dosimetry practice in radiotherapy centers. Findings demonstrate the rapid take-up of the TG-51 photon beam addendum and raise issues for the WGTG51 to focus on going forward, including guidelines on ancillary equipment and the choice of chamber for electron beam dosimetry.

TU-AB-BRB-01: Coverage Evaluation and Probabilistic Treatment Planning as a Margin Alternative

The accepted clinical method to accommodate targeting uncertainties inherent in fractionated external beam radiation therapy is to utilize GTV-to-CTV and CTV-to-PTV margins during the planning process to design a PTV-conformal static dose distribution on the planning image set. Ideally, margins are selected to ensure a high (e.g. >95%) target coverage probability (CP) in spite of inherent inter- and intra-fractional positional variations, tissue motions, and initial contouring uncertainties.nRobust optimization techniques, also known as probabilistic treatment planning techniques, explicitly incorporate the dosimetric consequences of targeting uncertainties by including CP evaluation into the planning optimization process along with coverage-based planning objectives. The treatment planner no longer needs to use PTV and/or PRV margins; instead robust optimization utilizes probability distributions of the underlying uncertainties in conjunction with CP-evaluation for the underlying CTVs and OARs to design an optimal treated volume.nThis symposium will describe CP-evaluation methods as well as various robust planning techniques including use of probability-weighted dose distributions, probability-weighted objective functions, and coverage optimized planning. Methods to compute and display the effect of uncertainties on dose distributions will be presented. The use of robust planning to accommodate inter-fractional setup uncertainties, organ deformation, and contouring uncertainties will be examined as will its use to accommodate intra-fractional organ motion. Clinical examples will be used to inter-compare robust and margin-based planning, highlighting advantages of robust-plans in terms of target and normal tissue coverage. Robust-planning limitations as uncertainties approach zero and as the number of treatment fractions becomes small will be presented, as well as the factors limiting clinical implementation of robust planning.nLearning Objectives:n1.xa0nTo understand robust-planning as a clinical alternative to using margin-based planning.n2.xa0nTo understand conceptual differences between uncertainty and predictable motion.n3.xa0nTo understand fundamental limitations of the PTV concept that probabilistic planning can overcome.n4.xa0nTo understand the major contributing factors to target and normal tissue coverage probability.n5.xa0nTo understand the similarities and differences of various robust planning techniquesn6.xa0nTo understand the benefits and limitations of robust planning techniques

TU-AB-BRB-00: New Methods to Ensure Target Coverage

The accepted clinical method to accommodate targeting uncertainties inherent in fractionated external beam radiation therapy is to utilize GTV-to-CTV and CTV-to-PTV margins during the planning process to design a PTV-conformal static dose distribution on the planning image set. Ideally, margins are selected to ensure a high (e.g. >95%) target coverage probability (CP) in spite of inherent inter- and intra-fractional positional variations, tissue motions, and initial contouring uncertainties.nRobust optimization techniques, also known as probabilistic treatment planning techniques, explicitly incorporate the dosimetric consequences of targeting uncertainties by including CP evaluation into the planning optimization process along with coverage-based planning objectives. The treatment planner no longer needs to use PTV and/or PRV margins; instead robust optimization utilizes probability distributions of the underlying uncertainties in conjunction with CP-evaluation for the underlying CTVs and OARs to design an optimal treated volume.nThis symposium will describe CP-evaluation methods as well as various robust planning techniques including use of probability-weighted dose distributions, probability-weighted objective functions, and coverage optimized planning. Methods to compute and display the effect of uncertainties on dose distributions will be presented. The use of robust planning to accommodate inter-fractional setup uncertainties, organ deformation, and contouring uncertainties will be examined as will its use to accommodate intra-fractional organ motion. Clinical examples will be used to inter-compare robust and margin-based planning, highlighting advantages of robust-plans in terms of target and normal tissue coverage. Robust-planning limitations as uncertainties approach zero and as the number of treatment fractions becomes small will be presented, as well as the factors limiting clinical implementation of robust planning.nLearning Objectives:n1.xa0nTo understand robust-planning as a clinical alternative to using margin-based planning.n2.xa0nTo understand conceptual differences between uncertainty and predictable motion.n3.xa0nTo understand fundamental limitations of the PTV concept that probabilistic planning can overcome.n4.xa0nTo understand the major contributing factors to target and normal tissue coverage probability.n5.xa0nTo understand the similarities and differences of various robust planning techniquesn6.xa0nTo understand the benefits and limitations of robust planning techniques