M Wagar

Evaluation of the interplay effect when using RapidArc to treat targets moving in the craniocaudal or right-left direction

PURPOSE We have investigated the dosimetric errors caused by the interplay between the motions of the LINAC and the tumor during the delivery of a volume modulated arc therapy treatment. This includes the development of an IMRT QA technique, applied here to evaluate RapidArc plans of varying complexity. METHODS An IMRT QA technique was developed, which involves taking a movie of the delivered dose (0.2 s frames) using a 2D ion chamber array. Each frame of the movie is then moved according to a respiratory trace and the cumulative dose calculated. The advantage of this approach is that the impact of turning the beam on at different points in the respiratory trace, and of different types of motion, can be evaluated using data from a single irradiation. We evaluated this technique by comparing with the results when we actually moved the phantom during irradiation. RapidArc plans were created to treat a 62 cc spherical tumor in a lung phantom (16 plans) and a 454 cc irregular tumor in an actual patient (five plans). The complexity of each field was controlled by adjusting the MU (312-966 MU). Each plan was delivered to a phantom, and a movie of the delivered dose taken using a 2D ion chamber array. Patient motion was modeled by shifting each dose frame according to a respiratory trace, starting the motion at different phases. The expected dose distribution was calculated by blurring the static dose distribution with the target motion. The dose error due to the interplay effect was then calculated by comparing the delivered dose with the expected dose distribution. Peak-to-peak motion of 0.5, 1.0, and 2.0 cm in the craniocaudal and right-left directions, with target periods of 3 and 5 s, were evaluated for each plan (252 different target motion/plan combinations). RESULTS The daily dose error due to the interplay effect was less than 10% for 98.4% of all pixels in the target for all plans investigated. The percentage of pixels for which the daily dose error could be larger than 5% increased with increasing plan complexity (field MU), but was less than 15% for all plans if the motion was 1 cm or less. For 2 cm motion, the dose error could be larger than 5% for 40% of pixels, but was less than 5% for more than 80% of pixels for MU < 550, and was less than 10% for 99% of all pixels. The interplay effect was smaller for 3 s periods than for 5 s periods. CONCLUSIONS The interplay between the motions of the LINAC and the target can result in an error in the delivered dose. This effect increases with plan complexity, and with target magnitude and period. It may average out after many fractions.

Angular dose dependency of MatriXX TM and its calibration

One of the applications of MatriXX (IBA Dosimetry) is experimental verification of dose for IMRT, VMAT, and tomotherapy. For cumulative plan verification, dose is delivered for all the treatment gantry angles to a stationary detector. Experimental calibration of MatriXX detector recommended by the manufacturer involves only AP calibration fields and does not address angular dependency of MatriXX. Angular dependency may introduce dose bias in cumulative plan verification if not corrected. For this reason, we characterized angular dependency of MatriXX and developed a method for its calibration. We found relatively large discrepancies in responses to posterior vs. anterior fields for four MatriXX (Evolution series) detectors (up to 11%), and relatively large variability of responses as a function of gantry angle in the gantry angle ranges of 91°–110° and 269°–260°. With our calibration method, the bias due to angular dependency is effectively removed in experimental verification of IMRT and VMAT plans. PACS number: 87.56Fc

Management of the interplay effect when using dynamic MLC sequences to treat moving targets

Interplay between organ motion and leaf motion has been shown to generally have a small dosimetric impact for most clinical intensity-modulated radiation therapy treatments. However, it has also been shown that for some MLC sequences there can be large daily variations in the delivered dose, depending on details of patient motion or the number of fractions. This study investigates guidelines for dynamic MLC sequences that will keep daily dose variations due to the interplay between organ motion and leaf motion within 10%. Dose distributions for a range of MLC separations (0.2-5.0 cm) and displacements between adjacent MLCs (0-1.5 cm) were exported from ECLIPSE to purpose-written software, which simulated the dose distribution delivered to a moving target. Target motion parallel and perpendicular to the MLC motion was investigated for a range of amplitudes (0.5-4.0 cm), periods (1.5-10 s), and MLC speeds (0.1-3.0 cm/s) with target motions modeled as sin. Results were confirmed experimentally by measuring the dose delivered to an ion chamber array in a moving phantom for different MLC sequences. The simulation results were used to identify MLC sequences that kept dose variations within 10% compared to the dose delivered with no motion. The maximum allowable MLC speed, when target motion is parallel to the MLC motion, was found to be a simple function of target period and MLC separation. When the target motion is perpendicular to MLC motion, the maximum allowable MLC speed can be described as a function of MLC separation and the displacement of adjacent MLCs. These guidelines were successfully applied to two-dimensional motion, and a simple program was written to import MLC sequence files and evaluate whether the maximum daily dose discrepancy caused by the interplay effect will be larger than 10%. This software was experimentally evaluated, and found to conservatively predict whether a given MLC sequence could give large daily dose discrepancies.

Use of reduced dose rate when treating moving tumors using dynamic IMRT

The purpose was to evaluate the effect of dose rate on discrepancies between expected and delivered dose caused by the interplay effect. Fifteen separate dynamic IMRT plans and five hybrid IMRT plans were created for five patients (three IMRT plans and one hybrid IMRT plan per patient). The impact of motion on the delivered dose was evaluated experimentally for each treatment field for different dose rates (200 and 400 MU/min), and for a range of target amplitudes and periods. The maximum dose discrepancy for dynamic IMRT fields was 18.5% and 10.3% for dose rates of 400 and 200 MU/min, respectively. The maximum dose discrepancy was larger than this for hybrid plans, but the results were similar when weighted by the contribution of the IMRT fields. The percentage of fields for which 98% of the target never experienced a 5% or 10% dose discrepancy increased when the dose rate was reduced from 400 MU/min to 200 MU/min. For amplitudes up to 2 cm, reducing the dose rate to 200 MU/min is effective in keeping daily dose discrepancies for each field within 10%. PACS number: 87.55Qr

Key clinical beam parameters for nanoparticle-mediated radiation dose amplification

As nanoparticle solutions move towards human clinical trials in radiation therapy, the influence of key clinical beam parameters on therapeutic efficacy must be considered. In this study, we have investigated the clinical radiation therapy delivery variables that may significantly affect nanoparticle-mediated radiation dose amplification. We found a benefit for situations which increased the proportion of low energy photons in the incident beam. Most notably, “unflattened” photon beams from a clinical linear accelerator results in improved outcomes relative to conventional “flat” beams. This is measured by significant DNA damage, tumor growth suppression, and overall improvement in survival in a pancreatic tumor model. These results, obtained in a clinical setting, clearly demonstrate the influence and importance of radiation therapy parameters that will impact clinical radiation dose amplification with nanoparticles.

Evaluation of initial setup accuracy and intrafraction motion for spine stereotactic body radiation therapy using stereotactic body frames

PURPOSE The purposes of this study were (1) to evaluate the initial setup accuracy and intrafraction motion for spine stereotactic body radiation therapy (SBRT) using stereotactic body frames (SBFs) and (2) to validate an in-house-developed SBF using a commercial SBF as a benchmark. METHODS AND MATERIALS Thirty-two spine SBRT patients (34 sites, 118 fractions) were immobilized with the Elekta and in-house (BHS) SBFs. All patients were set up with the Brainlab ExacTrac system, which includes infrared and stereoscopic kilovoltage x-ray-based positioning. Patients were initially positioned in the frame with the use of skin tattoos and then shifted to the treatment isocenter based on infrared markers affixed to the frame with known geometry relative to the isocenter. ExacTrac kV imaging was acquired, and automatic 6D (6 degrees of freedom) bony fusion was performed. The resulting translations and rotations gave the initial setup accuracy. These translations and rotations were corrected for by use of a robotic couch, and verification imaging was acquired that yielded residual setup error. The imaging/fusion process was repeated multiple times during treatment to provide intrafraction motion data. RESULTS The BHS SBF had greater initial setup errors (mean±SD): -3.9±5.5mm (0.2±0.9°), -1.6±6.0mm (0.5±1.4°), and 0.0±5.3mm (0.8±1.0°), respectively, in the vertical (VRT), longitudinal (LNG), and lateral (LAT) directions. The corresponding values were 0.6±2.7mm (0.2±0.6°), 0.9±5.3mm (-0.2±0.9°), and -0.9±3.0mm (0.3±0.9°) for the Elekta SBF. The residual setup errors were essentially the same for both frames and were -0.1±0.4mm (0.1±0.5°), -0.2±0.4mm (0.0±0.4°), and 0.0±0.4mm (0.0±0.4°), respectively, in VRT, LNG, and LAT. The intrafraction shifts in VRT, LNG, and LAT were 0.0±0.4mm (0.0±0.3°), 0.0±0.5mm (0.0±0.4°), and 0.0±0.4mm (0.0±0.3°), with no significant difference observed between the 2 frames. CONCLUSIONS These results showed that the combination of the ExacTrac system with either SBF was highly effective in achieving both setup accuracy and intrafraction stability, which were on par with that of mask-based cranial radiosurgery.

3D fluoroscopic image estimation using patient-specific 4DCBCT-based motion models

3D fluoroscopic images represent volumetric patient anatomy during treatment with high spatial and temporal resolution. 3D fluoroscopic images estimated using motion models built using 4DCT images, taken days or weeks prior to treatment, do not reliably represent patient anatomy during treatment. In this study we developed and performed initial evaluation of techniques to develop patient-specific motion models from 4D cone-beam CT (4DCBCT) images, taken immediately before treatment, and used these models to estimate 3D fluoroscopic images based on 2D kV projections captured during treatment. We evaluate the accuracy of 3D fluoroscopic images by comparison to ground truth digital and physical phantom images. The performance of 4DCBCT-based and 4DCT-based motion models are compared in simulated clinical situations representing tumor baseline shift or initial patient positioning errors. The results of this study demonstrate the ability for 4DCBCT imaging to generate motion models that can account for changes that cannot be accounted for with 4DCT-based motion models. When simulating tumor baseline shift and patient positioning errors of up to 5 mm, the average tumor localization error and the 95th percentile error in six datasets were 1.20 and 2.2 mm, respectively, for 4DCBCT-based motion models. 4DCT-based motion models applied to the same six datasets resulted in average tumor localization error and the 95th percentile error of 4.18 and 5.4 mm, respectively. Analysis of voxel-wise intensity differences was also conducted for all experiments. In summary, this study demonstrates the feasibility of 4DCBCT-based 3D fluoroscopic image generation in digital and physical phantoms and shows the potential advantage of 4DCBCT-based 3D fluoroscopic image estimation when there are changes in anatomy between the time of 4DCT imaging and the time of treatment delivery.

Effect of respiratory trace shape on optimal treatment margin

PURPOSE To evaluate the effect of target trajectory shape on the optimal treatment margin. METHODS Intensity-modulated radiation therapy and volumetric modulated arc therapy plans were created for three spherical targets (3, 5, and 7 cm diameter) simulated in exhalation phases, each with margins of 2, 4, 6, 8, and 10 mm to account for motion. The plans were delivered to a stationary 2D ion chamber array, and dose movies were obtained of the delivered doses. The dose movie frames were then displaced to simulate different respiratory traces. Five traces were used: sin2, sin4 sin6, and two patient traces. The optimal margin was defined as the margin for which the dose delivered to 95% of the target was closest to that obtained with no margin or motion. The equivalent uniform dose was also investigated as an alternative cost function. RESULTS The optimal margin was always smaller than the peak-to-peak motion. When the respiratory trace spent less time in the inhale phases, the optimal margin was consistently smaller than when more time was spent in the inhale phases. The target size and treatment modality also affected the optimal margin. CONCLUSIONS The necessary margin for targets that spend less time in the exhale phase (sin6) is 2-4 mm smaller than for targets that spend equal time in the inhale and exhale phases (sin).

Inter-scan and inter-observer tumour volume delineation variability on cone beam computed tomography in patients treated with stereotactic body radiation therapy for early-stage non-small cell lung cancer.

Quantification of volume changes on cone beam computed tomography (CBCT) during lung stereotactic body radiation therapy (SBRT) for non‐small cell lung cancer (NSCLC) may provide a useful radiological marker for radiation response and for adaptive treatment planning. This study quantifies inter‐scan and inter‐observer variability in tumour volume delineation on CBCT.

SU-F-T-410: Investigation of Treatment Planning Accuracy with the Presence of Magnetic Injection Port (breast Tissue Expander)

PURPOSE Mastectomy patients with breast reconstruction usually have a magnetic injection port inside the breast during radiation treatments. The magnet has a very high CT number and produces severe streaking artifact across the entire breast in CT images. Our routine strategy is to replace the artifact volumes with uniform water, and it is necessary to validate that the planned dose, with such an artifact correction, is sufficiently accurate. METHODS A phantom was made with a gelatine-filled container sitting on a Matrixx detector, and the magnetic port was inserted into gelatine with specific depths and orientations. The phantom was scanned on a CT simulator and imported into Eclipse for treatment planning. The dose distribution at the Matrixx detector plane was calculated for raw CT images and artifact-corrected images. The treatment beams were then delivered to the phantom and the dose distributions were acquired by the Matrixx detector. Gamma index was calculated to compare the planned dose and the measurement. RESULTS Three field sizes (10×10, 15×15 and 20×20) and two depths (50mm and 20mm) were investigated. With the 2%/2mm or 3%/3mm criteria, several points (6-10) failed in the plan for raw CT images, and the number of failure was reduced close to zero for the corrected CT images. An assignment of 10,000 HU to the magnet further reduced the dose error directly under the magnet. CONCLUSION It is validated that our routine strategy of artifact correction can effectively reduce the number of failures in the detector plane. It is also recommended to set the magnet with a CT number of 10,000HU, which could potentially improve the dose calculation at the points right behind the magnet.