K Kisling

Experimental validation of deterministic Acuros XB algorithm for IMRT and VMAT dose calculations with the Radiological Physics Center's head and neck phantom.

PURPOSE The purpose of this study was to verify the dosimetric performance of Acuros XB (AXB), a grid-based Boltzmann solver, in intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT). METHODS The Radiological Physics Center (RPC) head and neck (H&N) phantom was used for all calculations and measurements in this study. Clinically equivalent IMRT and VMAT plans were created on the RPC H&N phantom in the Eclipse treatment planning system (version 10.0) by using RPC dose prescription specifications. The dose distributions were calculated with two different algorithms, AXB 11.0.03 and anisotropic analytical algorithm (AAA) 10.0.24. Two dose report modes of AXB were recorded: dose-to-medium in medium (D(m,m)) and dose-to-water in medium (D(w,m)). Each treatment plan was delivered to the RPC phantom three times for reproducibility by using a Varian Clinac iX linear accelerator. Absolute point dose and planar dose were measured with thermoluminescent dosimeters (TLDs) and GafChromic® EBT2 film, respectively. Profile comparison and 2D gamma analysis were used to quantify the agreement between the film measurements and the calculated dose distributions from both AXB and AAA. The computation times for AAA and AXB were also evaluated. RESULTS Good agreement was observed between measured doses and those calculated with AAA or AXB. Both AAA and AXB calculated doses within 5% of TLD measurements in both the IMRT and VMAT plans. Results of AXB_D(m,m) (0.1% to 3.6%) were slightly better than AAA (0.2% to 4.6%) or AXB_D(w,m) (0.3% to 5.1%). The gamma analysis for both AAA and AXB met the RPC 7%/4 mm criteria (over 90% passed), whereas AXB_D(m,m) met 5%/3 mm criteria in most cases. AAA was 2 to 3 times faster than AXB for IMRT, whereas AXB was 4-6 times faster than AAA for VMAT. CONCLUSIONS AXB was found to be satisfactorily accurate when compared to measurements in the RPC H&N phantom. Compared with AAA, AXB results were equal to or better than those obtained with film measurements for IMRT and VMAT plans. The AXB_D(m,m) reporting mode was found to be closer to TLD and film measurements than was the AXB_D(w,m) mode. AXB calculation time was found to be significantly shorter (× 4) than AAA for VMAT.

Commissioning results of an automated treatment planning verification system

A dose calculation verification system (VS) was acquired and commissioned as a second check on the treatment planning system (TPS). This system reads DICOM CT datasets, RT plans, RT structures, and RT dose from the TPS and automatically, using its own collapsed cone superposition/convolution algorithm, computes dose on the same CT dataset. The system was commissioned by extracting basic beam parameters for simple field geometries and dose verification for complex treatments. Percent depth doses (PDD) and profiles were extracted for field sizes using jaw settings 3 × 3 cm2 ‐ 40 × 40 cm2 and compared to measured data, as well as our TPS model. Smaller fields of 1 × 1 cm2 and 2 × 2 cm2 generated using the multileaf collimator (MLC) were analyzed in the same fashion as the open fields. In addition, 40 patient plans consisting of both IMRT and VMAT were computed and the following comparisons were made: 1) TPS to the VS, 2) VS to measured data, and 3) TPS to measured data where measured data is both ion chamber (IC) and film measurements. Our results indicated for all field sizes using jaw settings PDD errors for the VS on average were less than 0.87%, 1.38%, and 1.07% for 6x, 15x, and 18x, respectively, relative to measured data. PDD errors for MLC field sizes were less than 2.28%, 1.02%, and 2.23% for 6x, 15x, and 18x, respectively. The infield profile analysis yielded results less than 0.58% for 6x, 0.61% for 15x, and 0.77% for 18x for the VS relative to measured data. Analysis of the penumbra region yields results ranging from 66.5% points, meeting the DTA criteria to 100% of the points for smaller field sizes for all energies. Analysis of profile data for field sizes generated using the MLC saw agreement with infield DTA analysis ranging from 68.8%–100% points passing the 1.5%/1.5 mm criteria. Results from the dose verification for IMRT and VMAT beams indicated that, on average, the ratio of TPS to IC and VS to IC measurements was 100.5 ± 1.9% and 100.4 ± 1.3%, respectively, while our TPS to VS was 100.1 ± 1.0%. When comparing the TPS and VS to film measurements, the average percentage pixels passing a 3%/3 mm criteria based gamma analysis were 96.6 ± 4.2% and 97 ± 5.6%, respectively. When the VS was compared to the TPS, on average 98.1 ± 5.3% of pixels passed the gamma analysis. Based upon these preliminary results, the VS system should be able to calculate dose adequately as a verification tool of our TPS. PACS number: 87.55.km

On the feasibility of treating to a 1.5 cm PTV with a commercial single-entry hybrid applicator in APBI breast brachytherapy

Purpose To evaluate and determine whether 30 patients previously treated with the SAVI™ device could have been treated to a PTV_EVAL created with a 1.5 cm expansion. This determination was based upon dosimetric parameters derived from current recommendations and dose-response data. Material and methods Thirty patients were retrospectively planned with PTV_EVALs generated with a 1.5 cm expansion (PTV_EVAL_1.5). Plans were evaluated based on PTV_EVAL_1.5 coverage (V90, V95, V100), skin and rib maximum doses (0.1 cc maximum dose as a percentage of prescription dose), as well as V150 and V200 for the PTV_EVAL_1.5. The treatment planning goal was to deliver ≥90% of the prescribed dose to ≥90% of the PTV_EVAL_1.5. Skin and rib maximum doses were to be ≤125% of the prescription dose and preferably ≤100% of the prescription dose. V150 and V200 were not allowed to exceed 52.5 cc and 21 cc, respectively. Plans not meeting the above criteria were recomputed with a 1.25 cm expanded PTV_EVAL and re-evaluated. Results Based on the above dose constraints, 30% (9/30) of the patients evaluated could have been treated with a 1.5 cm PTV_EVAL. The breakdown of cases successfully achieving the above dose constraints by applicator was: 0/4 (0%) 6-1, 6/15 (40%) 8-1, and 3/11 (27%) 10-1. For these PTV_EVAL_1.5 plans, median V90% was 90.3%, whereas the maximum skin and rib doses were all less than 115.2% and 117.6%, respectively. The median V150 and V200 volumes were 39.2 cc and 19.3, respectively. The treated PTV_EVAL_1.5 was greater in volume than the PTV_EVAL by 41.7 cc, and 60 cc for the 8-1, and 10-1 applicators, respectively. All remaining plans (17) successfully met the above dose constraints to be treated with a 1.25 cm PTV_EVAL (PTV_EVAL_1.25). For the PTV_EVAL_1.25 plans, V90% was 93.7%, and the maximum skin and rib doses were all less than 109.2% and 102.5%, respectively. The median V150 and V200 volumes were 41.2 cc and 19.3, respectively. The treated PTV_EVAL_1.25 was greater in volume than the PTV_EVAL by 16 cc, 24.9 cc, and 33.5 cc for the 6-1, 8-1 and 10-1 applicators, respectively. Conclusions It is dosimetrically possible to treat beyond the currently advised 1.0 cm expanded PTV_EVAL. Most patients should be able to be treated with a 1.25 cm PTV_EVAL and a select group with a 1.5 cm PTV_EVAL. Applicator size appears to determine the ability to expand to a 1.5 cm PTV_EVAL, as smaller devices were not as propitious in this regard. Further studies may identify additional patient groups that would benefit from this approach.

TU-H-CAMPUS-JeP1-02: Fully Automatic Verification of Automatically Contoured Normal Tissues in the Head and Neck

PURPOSE To investigate and validate the use of an independent deformable-based contouring algorithm for automatic verification of auto-contoured structures in the head and neck towards fully automated treatment planning. METHODS Two independent automatic contouring algorithms [(1) Eclipses Smart Segmentation followed by pixel-wise majority voting, (2) an in-house multi-atlas based method] were used to create contours of 6 normal structures of 10 head-and-neck patients. After rating by a radiation oncologist, the higher performing algorithm was selected as the primary contouring method, the other used for automatic verification of the primary. To determine the ability of the verification algorithm to detect incorrect contours, contours from the primary method were shifted from 0.5 to 2cm. Using a logit model the structure-specific minimum detectable shift was identified. The models were then applied to a set of twenty different patients and the sensitivity and specificity of the models verified. RESULTS Per physician rating, the multi-atlas method (4.8/5 point scale, with 3 rated as generally acceptable for planning purposes) was selected as primary and the Eclipse-based method (3.5/5) for verification. Mean distance to agreement and true positive rate were selected as covariates in an optimized logit model. These models, when applied to a group of twenty different patients, indicated that shifts could be detected at 0.5cm (brain), 0.75cm (mandible, cord), 1cm (brainstem, cochlea), or 1.25cm (parotid), with sensitivity and specificity greater than 0.95. If sensitivity and specificity constraints are reduced to 0.9, detectable shifts of mandible and brainstem were reduced by 0.25cm. These shifts represent additional safety margins which might be considered if auto-contours are used for automatic treatment planning without physician review. CONCLUSION Automatically contoured structures can be automatically verified. This fully automated process could be used to flag auto-contours for special review or used with safety margins in a fully automatic treatment planning system.

Contralateral breast dose from partial breast brachytherapy.

The purpose of this study was to determine the dose to the contralateral breast during accelerated partial breast irradiation (APBI) and to compare it to external beam‐published values. Thermoluminescent dosimeter (TLD) packets were used to measure the dose to the most medial aspect of the contralateral breast during APBI simulation, daily quality assurance (QA), and treatment. All patients in this study were treated with a single‐entry, multicatheter device for 10 fractions to a total dose of 34 Gy. A mark was placed on the patients skin on the medial aspect of the opposite breast. Three TLD packets were taped to this mark during the pretreatment simulation. Simulations consisted of an AP and Lateral scout and a limited axial scan encompassing the lumpectomy cavity (miniscan), if rotation was a concern. After the simulation the TLD packets were removed and the patients were moved to the high‐dose‐rate (HDR) vault where three new TLD packets were taped onto the patients at the skin mark. Treatment was administered with a Nucletron HDR afterloader using Iridium‐192 as the treatment source. Post‐treatment, TLDs were read (along with the simulation and QA TLD and a set of standards exposed to a known dose of 6 MV photons). Measurements indicate an average total dose to the contralateral breast of 70 cGy for outer quadrant implants and 181 cGy for inner quadrant implants. Compared to external beam breast tangents, these results point to less dose being delivered to the contralateral breast when using APBI. PACS number: 87.55.D‐The purpose of this study was to determine the dose to the contralateral breast during accelerated partial breast irradiation (APBI) and to compare it to external beam-published values. Thermoluminescent dosimeter (TLD) packets were used to measure the dose to the most medial aspect of the contralateral breast during APBI simulation, daily quality assurance (QA), and treatment. All patients in this study were treated with a single-entry, multicatheter device for 10 fractions to a total dose of 34 Gy. A mark was placed on the patients skin on the medial aspect of the opposite breast. Three TLD packets were taped to this mark during the pretreatment simulation. Simulations consisted of an AP and Lateral scout and a limited axial scan encompassing the lumpectomy cavity (miniscan), if rotation was a concern. After the simulation the TLD packets were removed and the patients were moved to the high-dose-rate (HDR) vault where three new TLD packets were taped onto the patients at the skin mark. Treatment was administered with a Nucletron HDR afterloader using Iridium-192 as the treatment source. Post-treatment, TLDs were read (along with the simulation and QA TLD and a set of standards exposed to a known dose of 6 MV photons). Measurements indicate an average total dose to the contralateral breast of 70 cGy for outer quadrant implants and 181 cGy for inner quadrant implants. Compared to external beam breast tangents, these results point to less dose being delivered to the contralateral breast when using APBI. PACS number: 87.55.D.

SU‐GG‐T‐39: Grid‐Based Boltzmann Solver (GBBS) vs TG‐43 for Ir‐192 HDR Intracavitary Brachytherapy: A Retrospective Dosimetric Study

Purpose: To determine dosimetric differences between a grid‐based Boltzmann solver (GBBS) and TG‐43 for a cohort of HDR cervical cancer cases treated using the CT/MR Fletcher‐Suit‐Delclos (FSD) type applicator. Method and Materials:Dose distributions from a cohort (n=10) of cervical cancer patients treated with the VS2000 192Ir HDR source were analyzed retrospectively using the BrachyVision‐Acuros v8.8 TPS. A single physician contoured the rectum and bladder. 6 Gy was prescribed to point A. Doses were recorded for ICRU rectal and bladder points as well as vaginal surfaces. Rectum, bladder, and entire dose grid DVHs were visually assessed and compared at relevant points. Dose grids were exported to IDL to calculate mean voxel percent differences. Average, minimum, and maximum percent dose differences are reported for 1) D2cc and D90 for rectum and bladder and for 2) dose grid mean voxel percent difference. Results: Visual inspection of DVH showed lateral shifting of GBBS curves to lower doses. The shifting was noticeable for dose levels within 4 Gy. Percent difference results from the DVH output: D2cc‐Rectum: −2.1%(mean) [−3.0%(min), −0.5%(max)]; D90‐Rectum: −2.3% [−7.5%, 4.6%]; D2cc‐Bladder: −0.7% [−1.8%, 0.7%]; D90‐Bladder: −4.4% [−7.0%, −2.2%]. All ICRU points studied had dose differences within −3.3% relative to TG‐43. The average of the mean voxel percent difference for the entire dose grid was −1.3% and ranged from −3.7% to 1.2%. Visualization of individual percent difference maps overlaid on CT revealed lower GBBS doses behind contrast filled balloon in the bladder. Conclusions: For this cohort of patients that underwent intracavitary HDR brachytherapy with the CT/MR FSD applicator, the GBBS calculated dose to clinical reference points and hot spots (D2cc) was within 3.3% of TG‐43. Over the entire dose grid, however, lateral shifting of DVHs to lower doses was observed. This may be partially due to contrast filled balloon in bladder.

Radiation planning assistant - A streamlined, fully automated radiotherapy treatment planning system

The Radiation Planning Assistant (RPA) is a system developed for the fully automated creation of radiotherapy treatment plans, including volume-modulated arc therapy (VMAT) plans for patients with head/neck cancer and 4-field box plans for patients with cervical cancer. It is a combination of specially developed in-house software that uses an application programming interface to communicate with a commercial radiotherapy treatment planning system. It also interfaces with a commercial secondary dose verification software. The necessary inputs to the system are a Treatment Plan Order, approved by the radiation oncologist, and a simulation computed tomography (CT) image, approved by the radiographer. The RPA then generates a complete radiotherapy treatment plan. For the cervical cancer treatment plans, no additional user intervention is necessary until the plan is complete. For head/neck treatment plans, after the normal tissue and some of the target structures are automatically delineated on the CT image, the radiation oncologist must review the contours, making edits if necessary. They also delineate the gross tumor volume. The RPA then completes the treatment planning process, creating a VMAT plan. Finally, the completed plan must be reviewed by qualified clinical staff.

A snapshot of medical physics practice patterns

Abstract A large number of surveys have been sent to the medical physics community addressing many clinical topics for which the medical physicist is, or may be, responsible. Each survey provides an insight into clinical practice relevant to the medical physics community. The goal of this study was to create a summary of these surveys giving a snapshot of clinical practice patterns. Surveys used in this study were created using SurveyMonkey and distributed between February 6, 2013 and January 2, 2018 via the MEDPHYS and MEDDOS listserv groups. The format of the surveys included questions that were multiple choice and free response. Surveys were included in this analysis if they met the following criteria: more than 20 responses, relevant to radiation therapy physics practice, not single‐vendor specific, and formatted as multiple‐choice questions (i.e., not exclusively free‐text responses). Although the results of free response questions were not explicitly reported, they were carefully reviewed, and the responses were considered in the discussion of each topic. Two‐hundred and fifty‐two surveys were available, of which 139 passed the inclusion criteria. The mean number of questions per survey was 4. The mean number of respondents per survey was 63. Summaries were made for the following topics: simulation, treatment planning, electron treatments, linac commissioning and quality assurance, setup and treatment verification, IMRT and VMAT treatments, SRS/SBRT, breast treatments, prostate treatments, brachytherapy, TBI, facial lesion treatments, clinical workflow, and after‐hours/emergent treatments. We have provided a coherent overview of medical physics practice according to surveys conducted over the last 5 yr, which will be instructive for medical physicists.

Dosimetric impact of setup accuracy for an electron breast boost technique

PURPOSE To determine the setup error on an electron breast boost technique using daily cone beam computed tomography (CBCT). Patient and setup attributes were studied as contributing factors to the accuracy. METHODS AND MATERIALS Reproducibility of a modified lateral decubitus position breast boost setup was verified for 33 patients using CBCT. Three-dimensional matching was performed between the CBCT and the initial planning CT for each boost fraction by matching the tumor bed and/or surgical clips. The dosimetric impact of the daily positioning error was achieved by rerunning the initial treatment plans incorporating the recorded shifts to study the dose differences. Breast compression, decubitus angle, tumor bed location and volume, and cup size were studied for their contribution to setup error. RESULTS The range of setup errors was: 1.5 cm anterior to 9 mm posterior, 1.3 cm superior to 2.3 cm inferior, and 3.2 cm medial to 2.4 cm lateral. Seven patients had setup errors that were ≥2-cm margin placed on the tumor bed and scar. Four of those 7 patients had unacceptable coverage as defined by the volume of the tumor bed plus scar that is covered by the 90% isodose line (V90) compared with the original plan. All other patients had no discernible difference in the coverage (V90). The use of compression, tumor bed location, or volumes >20 mL showed no effect on coverage. CONCLUSIONS In general, this study supported that a 2-cm margin was adequate (29 of 33 patients) when patients are treated under typical conditions. Care should be taken when high electron energies are selected because the coverage at depth is more difficult to maintain in the clinical environment.

SU-E-T-276: Dose Calculation Accuracy with a Standard Beam Model for Extended SSD Treatments

Purpose: While most photon treatments are delivered near 100cm SSD or less, a subset of patients may benefit from treatment at SSDs greater than 100cm. A proposed rotating chair for upright treatments would enable isocentric treatments at extended SSDs. The purpose of this study was to assess the accuracy of the Pinnacle3 treatment planning system dose calculation for standard beam geometries delivered at extended SSDs with a beam model commissioned at 100cm SSD. Methods: Dose to a water phantom at 100, 110, and 120cm SSD was calculated with the Pinnacle 3 CC convolve algorithm for 6x beams for 5×5, 10×10, 20×20, and 30×30cm2 field sizes (defined at the water surface for each SSD). PDDs and profiles (depths of 1.5, 12.5, and 22cm) were compared to measurements in water with an ionization chamber. Point-by-point agreement was analyzed, as well as agreement in field size defined by the 50% isodose. Results: The deviations of the calculated PDDs from measurement, analyzed from depth of maximum dose to 23cm, were all within 1.3% for all beam geometries. In particular, the calculated PDDs at 10cm depth were all within 0.7% of measurement. For profiles, the deviations within the central 80% of the field were within 2.2% for all geometries. The field sizes all agreed within 2mm. Conclusion: The agreement of the PDDs and profiles calculated by Pinnacle3 for extended SSD geometries were within the acceptability criteria defined by Van Dyk (±2% for PDDs and ±3% for profiles). The accuracy of the calculation of more complex beam geometries at extended SSDs will be investigated to further assess the feasibility of using a standard beam model commissioned at 100cm SSD in Pinnacle3 for extended SSD treatments.