Leah N. McDermott

A literature review of electronic portal imaging for radiotherapy dosimetry

Electronic portal imaging devices (EPIDs) have been the preferred tools for verification of patient positioning for radiotherapy in recent decades. Since EPID images contain dose information, many groups have investigated their use for radiotherapy dose measurement. With the introduction of the amorphous-silicon EPIDs, the interest in EPID dosimetry has been accelerated because of the favourable characteristics such as fast image acquisition, high resolution, digital format, and potential for in vivo measurements and 3D dose verification. As a result, the number of publications dealing with EPID dosimetry has increased considerably over the past approximately 15 years. The purpose of this paper was to review the information provided in these publications. Information available in the literature included dosimetric characteristics and calibration procedures of various types of EPIDs, strategies to use EPIDs for dose verification, clinical approaches to EPID dosimetry, ranging from point dose to full 3D dose distribution verification, and current clinical experience. Quality control of a linear accelerator, pre-treatment dose verification and in vivo dosimetry using EPIDs are now routinely used in a growing number of clinics. The use of EPIDs for dosimetry purposes has matured and is now a reliable and accurate dose verification method that can be used in a large number of situations. Methods to integrate 3D in vivo dosimetry and image-guided radiotherapy (IGRT) procedures, such as the use of kV or MV cone-beam CT, are under development. It has been shown that EPID dosimetry can play an integral role in the total chain of verification procedures that are implemented in a radiotherapy department. It provides a safety net for simple to advanced treatments, as well as a full account of the dose delivered. Despite these favourable characteristics and the vast range of publications on the subject, there is still a lack of commercially available solutions for EPID dosimetry. As strategies evolve and commercial products become available, EPID dosimetry has the potential to become an accurate and efficient means of large-scale patient-specific IMRT dose verification for any radiotherapy department.

Accurate two-dimensional IMRT verification using a back-projection EPID dosimetry method

The use of electronic portal imaging devices (EPIDs) is a promising method for the dosimetric verification of external beam, megavoltage radiation therapy-both pretreatment and in vivo. In this study, a previously developed EPID back-projection algorithm was modified for IMRT techniques and applied to an amorphous silicon EPID. By using this back-projection algorithm, two-dimensional dose distributions inside a phantom or patient are reconstructed from portal images. The model requires the primary dose component at the position of the EPID. A parametrized description of the lateral scatter within the imager was obtained from measurements with an ionization chamber in a miniphantom. In addition to point dose measurements on the central axis of square fields of different size, we also used dose profiles of those fields as reference input data for our model. This yielded a better description of the lateral scatter within the EPID, which resulted in a higher accuracy in the back-projected, two-dimensional dose distributions. The accuracy of our approach was tested for pretreatment verification of a five-field IMRT plan for the treatment of prostate cancer. Each field had between six and eight segments and was evaluated by comparing the back-projected, two-dimensional EPID dose distribution with a film measurement inside a homogeneous slab phantom. For this purpose, the y-evaluation method was used with a dose-difference criterion of 2% of dose maximum and a distance-to-agreement criterion of 2 mm. Excellent agreement was found between EPID and film measurements for each field, both in the central part of the beam and in the penumbra and low-dose regions. It can be concluded that our modified algorithm is able to accurately predict the dose in the midplane of a homogeneous slab phantom. For pretreatment IMRT plan verification, EPID dosimetry is a reliable and potentially fast tool to check the absolute dose in two dimensions inside a phantom for individual IMRT fields. Film measurements inside a phantom can therefore be replaced by EPID measurements.

Dose–response and ghosting effects of an amorphous silicon electronic portal imaging device

The purpose of this study was to investigate the dose-response characteristics, including ghosting effects, of an amorphous silicon-based electronic portal imaging device (a-Si EPID) under clinical conditions. EPID measurements were performed using one prototype and two commercial a-Si detectors on two linear accelerators: one with 4 and 6 MV and the other with 8 and 18 MV x-ray beams. First, the EPID signal and ionization chamber measurements in a mini-phantom were compared to determine the amount of buildup required for EPID dosimetry. Subsequently, EPID signal characteristics were studied as a function of dose per pulse, pulse repetition frequency (PRF) and total dose, as well as the effects of ghosting. There was an over-response of the EPID signal compared to the ionization chamber of up to 18%, with no additional buildup layer over an air gap range of 10 to 60 cm. The addition of a 2.5 mm thick copper plate sufficiently reduced this over-response to within 1% at clinically relevant patient-detector air gaps (> 40 cm). The response of the EPIDs varied by up to 8% over a large range of dose per pulse values, PRF values and number of monitor units. The EPID response showed an under-response at shorter beam times due to ghosting effects, which depended on the number of exposure frames for a fixed frame acquisition rate. With an appropriate build-up layer and corrections for dose per pulse, PRF and ghosting, the variation in the a-Si EPID response can be reduced to well within +/- 1%.

Catching errors with in vivo EPID dosimetry

The potential for detrimental incidents and the ever increasing complexity of patient treatments emphasize the need for accurate dosimetric verification in radiotherapy. For this reason, all curative treatments are verified, either pretreatment or in vivo, by electronic portal imaging device (EPID) dosimetry in the Radiation Oncology Department of the Netherlands Cancer Institute-Antoni van Leeuwenhoek hospital, Amsterdam, The Netherlands. Since the clinical introduction of the method in January 2005 until August 2009, treatment plans of 4337 patients have been verified. Among these plans, 17 serious errors were detected that led to intervention. Due to their origin, nine of these errors would not have been detected with pretreatment verification. The method is illustrated in detail by the case of a plan transfer error detected in a 5×5Gy intensity-modulated radiotherapy (IMRT) rectum treatment. The EPID reconstructed dose at the isocenter was 6.3% below the planned value. Investigation of the plan transfer chain revealed that due to a network transfer error, the plan was corrupted. 3D analysis of the acquired EPID data revealed serious underdosage of the planning target volume: On average 11.6%, locally up to 20%. This report shows the importance of in vivo (EPID) dosimetry for all treatment plans as well as the ability of the method to assess the dosimetric impact of deviations found.

A simple backprojection algorithm for 3D in vivo EPID dosimetry of IMRT treatments

Treatment plans are usually designed, optimized, and evaluated based on the total 3D dose distribution, motivating a total 3D dose verification. The purpose of this study was to develop a 2D transmission-dosimetry method using an electronic portal imaging device (EPID) into a simple 3D method that provides 3D dose information. In the new method, the dose is reconstructed within the patient volume in multiple planes parallel to the EPID for each gantry angle. By summing the 3D dose grids of all beams, the 3D dose distribution for the total treatment fraction is obtained. The algorithm uses patient contours from the planning CT scan but does not include tissue inhomogeneity corrections. The 3D EPID dosimetry method was tested for IMRT fractions of a prostate, a rectum, and a head-and-neck cancer patient. Planned and in vivo-measured dose distributions were within 2% at the dose prescription point. Within the 50% isodose surface of the prescribed dose, at least 97% of points were in agreement, evaluated with a 3D gamma method with criteria of 3% of the prescribed dose and 0.3 cm. Full 3D dose reconstruction on a 0.1 x 0.1 x 0.1 cm3 grid and 3D gamma evaluation took less than 15 min for one fraction on a standard PC. The method allows in vivo determination of 3D dose-volume parameters that are common in clinical practice. The authors conclude that their EPID dosimetry method is an accurate and fast tool for in vivo dose verification of IMRT plans in 3D. Their approach is independent of the treatment planning system and provides a practical safety net for radiotherapy.

Clinical experience with EPID dosimetry for prostate IMRT pre-treatment dose verification

The aim of this study was to demonstrate how dosimetry with an amorphous silicon electronic portal imaging device (a-Si EPID) replaced film and ionization chamber measurements for routine pre-treatment dosimetry in our clinic. Furthermore, we described how EPID dosimetry was used to solve a clinical problem. IMRT prostate plans were delivered to a homogeneous slab phantom. EPID transit images were acquired for each segment. A previously developed in-house back-projection algorithm was used to reconstruct the dose distribution in the phantom mid-plane (intersecting the isocenter). Segment dose images were summed to obtain an EPID mid-plane dose image for each field. Fields were compared using profiles and in two dimensions with the y evaluation (criteria: 3%/3 mm). To quantify results, the average gamma (gamma avg), maximum gamma (gamma max), and the percentage of points with gamma < 1(P gamma < 1) were calculated within the 20% isodose line of each field. For 10 patient plans, all fields were measured with EPID and film at gantry set to 0 degrees. The film was located in the phantom coronal mid-plane (10 cm depth), and compared with the back-projected EPID mid-plane absolute dose. EPID and film measurements agreed well for all 50 fields, with (gamma avg) =0.16, (gamma max)=1.00, and (P gamma < 1)= 100%. Based on these results, film measurements were discontinued for verification of prostate IMRT plans. For 20 patient plans, the dose distribution was re-calculated with the phantom CT scan and delivered to the phantom with the original gantry angles. The planned isocenter dose (plan(iso)) was verified with the EPID (EPID(iso)) and an ionization chamber (IC(iso)). The average ratio, (EPID(iso)/IC(iso)), was 1.00 (0.01 SD). Both measurements were systematically lower than planned, with (EPID(iso)/plan(iso)) and (IC(iso)/plan(iso))=0.99 (0.01 SD). EPID mid-plane dose images for each field were also compared with the corresponding plane derived from the three dimensional (3D) dose grid calculated with the phantom CT scan. Comparisons of 100 fields yielded (gamma avg)=0.39, gamma max=2.52, and (P gamma < 1)=98.7%. Seven plans revealed under-dosage in individual fields ranging from 5% to 16%, occurring at small regions of overlapping segments or along the junction of abutting segments (tongue-and-groove side). Test fields were designed to simulate errors and gave similar results. The agreement was improved after adjusting an incorrectly set tongue-and-groove width parameter in the treatment planning system (TPS), reducing (gamma max) from 2.19 to 0.80 for the test field. Mid-plane dose distributions determined with the EPID were consistent with film measurements in a slab phantom for all IMRT fields. Isocenter doses of the total plan measured with an EPID and an ionization chamber also agreed. The EPID can therefore replace these dosimetry devices for field-by-field and isocenter IMRT pre-treatment verification. Systematic errors were detected using EPID dosimetry, resulting in the adjustment of a TPS parameter and alteration of two clinical patient plans. One set of EPID measurements (i.e., one open and transit image acquired for each segment of the plan) is sufficient to check each IMRT plan field-by-field and at the isocenter, making it a useful, efficient, and accurate dosimetric tool.

Comparison of ghosting effects for three commercial a-Si EPIDs

Many studies have reported dosimetric characteristics of amorphous silicon electronic portal imaging devices (EPIDs). Some studies ascribed a non-linear signal to gain ghosting and image lag. Other reports, however, state the effect is negligible. This study compares the signal-to-monitor unit (MU) ratio for three different brands of EPID systems. The signal was measured for a wide range of monitor units (5-1000), dose-rates, and beam energies. All EPIDs exhibited a relative under-response for beams of few MUs; giving 4 to 10% lower signal-to-MU ratios relative to that of 1000 MUs. This under-response is consistent with ghosting effects due to charge trapping.

In aqua vivo EPID dosimetry

PURPOSE At the Netherlands Cancer Institute--Antoni van Leeuwenhoek Hospital in vivo dosimetry using an electronic portal imaging device (EPID) has been implemented for almost all high-energy photon treatments of cancer with curative intent. Lung cancer treatments were initially excluded, because the original back-projection dose-reconstruction algorithm uses water-based scatter-correction kernels and therefore does not account for tissue inhomogeneities accurately. The aim of this study was to test a new method, in aqua vivo EPID dosimetry, for fast dose verification of lung cancer irradiations during actual patient treatment. METHODS The key feature of our method is the dose reconstruction in the patient from EPID images, obtained during the actual treatment, whereby the images have been converted to a situation as if the patient consisted entirely of water; hence, the method is termed in aqua vivo. This is done by multiplying the measured in vivo EPID image with the ratio of two digitally reconstructed transmission images for the unit-density and inhomogeneous tissue situation. For dose verification, a comparison is made with the calculated dose distribution with the inhomogeneity correction switched off. IMRT treatment verification is performed for each beam in 2D using a 2D γ evaluation, while for the verification of volumetric-modulated arc therapy (VMAT) treatments in 3D a 3D γ evaluation is applied using the same parameters (3%, 3 mm). The method was tested using two inhomogeneous phantoms simulating a tumor in lung and measuring its sensitivity for patient positioning errors. Subsequently five IMRT and five VMAT clinical lung cancer treatments were investigated, using both the conventional back-projection algorithm and the in aqua vivo method. The verification results of the in aqua vivo method were statistically analyzed for 751 lung cancer patients treated with IMRT and 50 lung cancer patients treated with VMAT. RESULTS The improvements by applying the in aqua vivo approach are considerable. The percentage of γ values ≤1 increased on average from 66.2% to 93.1% and from 43.6% to 97.5% for the IMRT and VMAT cases, respectively. The corresponding mean γ value decreased from 0.99 to 0.43 for the IMRT cases and from 1.71 to 0.40 for the VMAT cases, which is similar to the accepted clinical values for the verification of IMRT treatments of prostate, rectum, and head-and-neck cancers. The deviation between the reconstructed and planned dose at the isocenter diminished on average from 5.3% to 0.5% for the VMAT patients and was almost the same, within 1%, for the IMRT cases. The in aqua vivo verification results for IMRT and VMAT treatments of a large group of patients had a mean γ of approximately 0.5, a percentage of γ values ≤1 larger than 89%, and a difference of the isocenter dose value less than 1%. CONCLUSIONS With the in aqua vivo approach for the verification of lung cancer treatments (IMRT and VMAT), we can achieve results with the same accuracy as obtained during in vivo EPID dosimetry of sites without large inhomogeneities.

TU‐C‐T‐6E‐06: First Clinical Experience with Pre‐Treatment and in Vivo IMRT Verification Using EPID Dosimetry

Purpose: The aim of this study was to verify the first IMRT prostate plans made in our clinic with a newly commissioned treatment planning system (TPS, Pinnacle 7.4f) using an amorphous siliconelectronic portal imaging device (a‐Si EPID, Elekta iViewGT), both pre‐treatment and in vivo. Method and Materials: For pre‐treatment verification, the plans of 8 patients were re‐calculated on a polystyrene slab phantom. An in‐house developed back‐projection algorithm was used to estimate the dose distribution at the phantom/patient isocentric mid‐plane (perpendicular to the beam‐axis) with the EPID. Each plan was also validated at the isocentre with ionization chamber measurements. Separate fields were measured with film and EPID, with gantry angle =0°. The in vivo mid‐plane dose was estimated with the EPID for the first 3 fractions and weekly thereafter. γ‐evaluation was used to assess 2D dose distributions with criteria of 3% dose difference (of maximum dose) and 3mm distance‐to‐agreement. The evaluated area included all points within the 20% isodose line of each EPID field. Anatomy changes for in vivo measurements were assessed using cone‐beam CT acquired prior to each verified fraction. Results: For pre‐treatment verification, the dose distributions of EPID vs. plan and EPID vs. film agreed within 3% or 3mm for 99.2% and 100% of points, respectively. The average ratio of the measured and planned isocentre dose was 0.987 ±0.003(SD) for ionization chamber and 0.997 ±0.009(SD) for EPID. For the in vivoyfields, 96.7% of dose points were in agreement. Examples of discrepancies were due to variation in gas pockets during treatment and problems calculating the dose distribution in a small area of overlapping segments (1cm2). Conclusion: These results show that an a‐Si EPID can be used to accurately verify IMRT prostate treatments in the mid‐plane of the phantom or patient, both pre‐treatment and in vivo.

WE‐D‐AUD‐06: In Vivo EPID Dosimetry for Large Scale Clinical IMRT Verification

Purpose: To introduce 2D in vivoEPIDdosimetry as a tool for IMRT verification in the clinic for all curative patients (about 2000/year) before the end of 2007; meanwhile replacing pre‐treatment dosimetry, reducing workload and improving efficiency. Method and Materials:EPIDimages are acquired per segment, and by means of a back‐projection algorithm converted to dose distributions in a plane intersecting the isocenter, perpendicular to the beam axis. In this plane, a 2D field‐by‐field comparison is performed between the back‐projected EPID and planned dose distributions, using the γ‐evaluation method with 3%/3mm of maximum dose as criteria. For each field the mean γ, maximum 1% γ, percentage of points in agreement, and the isocenter dose difference are reported. These numbers are fed into a decision rule setting limits on the approval of a treatment plan. Results: Currently, treatment plans of prostate, rectum, skull and livercancer patients are already validated based on in vivoEPIDmeasurements; for the other patient groups in vivodosimetry is being introduced. Statistics for a group of 152 prostate patients, each having 3–5 EPIDmeasurements thus filtering out random uncertainties, show an average mean γ‐value per patient of 0.41, and an average isocenter dose difference of −1.5% between EPID and plan. Clinically relevant errors were detected in four prostate plans, and these plans were replaced. Preliminary results for head&neck, breast and lungIMRT treatments show the feasibility of the method for these sites but inhomogeneity corrections need to be refined to improve accuracy. Conclusions: For a variety of treatment sites, 2D in vivoEPIDdosimetry is now clinically used, or will be introduced soon, for IMRT verification of all curative patients. In this way, an efficient and accurate routine procedure has been developed for routine purposes providing the radiotherapy chain with an extra safety net.