N Papanikolaou

QA for helical tomotherapy: Report of the AAPM Task Group 148

Helical tomotherapy is a relatively new modality with integrated treatment planning and delivery hardware for radiation therapy treatments. In view of the uniqueness of the hardware design of the helical tomotherapy unit and its implications in routine quality assurance, the Therapy Physics Committee of the American Association of Physicists in Medicine commissioned Task Group 148 to review this modality and make recommendations for quality assurance related methodologies. The specific objectives of this Task Group are: (a) To discuss quality assurance techniques, frequencies, and tolerances and (b) discuss dosimetric verification techniques applicable to this unit. This report summarizes the findings of the Task Group and aims to provide the practicing clinical medical physicist with the insight into the technology that is necessary to establish an independent and comprehensive quality assurance program for a helical tomotherapy unit. The emphasis of the report is to describe the rationale for the proposed QA program and to provide example tests that can be performed, drawing from the collective experience of the task group members and the published literature. It is expected that as technology continues to evolve, so will the test procedures that may be used in the future to perform comprehensive quality assurance for helical tomotherapy units.

Stereotactic body radiation therapy for centrally located lung lesions

Presentation of outcomes of patients treated by stereotactic body radiation therapy (SBRT) for lung lesions located within or touching a 2 cm zone around major airways. Serial tomotherapeutic SBRT has been planned and delivered at our institution since August 2001. Of 108 patients treated for primary and secondary lung tumors, nine harbored tumors (8 metastases, 1 recurrent NSCLC) located in close proximity to carina, right and left main bronchi, right and left upper lobe bronchi, intermedius, right middle lobe, lingular, or right and left lower lobe bronchi. SBRT was delivered to total doses of 36 Gy in 3 fractions (n = 8) or 6 fractions (n = 1), using a serial tomotherapy system (Nomos Peacock). We assessed local tumor control, clinical toxicity, normal tissue imaging changes, and overall survival. Median tumor volume was 26 cm3 (range 1.7 to 135 cm3). Tumor locations were hilar (n = 3), and parenchymal in six cases. Hilar lesions accounted for the three largest tumor volumes in the series. During a median follow-up of 10.6 months (range 2.5 to 41.5 months), all lesions treated were locally controlled as confirmed by CT or CT/PET imaging. Parenchymal imaging changes included focal lung fibrosis and major airway wall thickening. One occurrence of major airway occlusion (right lower lobe bronchus) was observed. This event was diagnosed by chest x-ray at 36 months, following treatment of the second largest hilar lesion in the present series. Based on the outcomes observed in this small sample series, SBRT for centrally located lung lesions appears feasible, was associated with low incidence of toxicities, and provided sustained local tumor control. However, long-term survival may be associated with major airway injury. As long-term follow-up in larger numbers of patients is lacking at this time, exclusion of patients with centrally located lesions may be considered when patients are treated in curative intent.

Tomotherapeutic stereotactic body radiation therapy: Techniques and comparison between modalities

Presentation and comparison of tomotherapeutic intensity-modulated techniques for planning and delivery of stereotactic body radiation therapy. Serial tomotherapeutic SBRT has been planned and delivered at our institution since 8/2001. Since 12/2005, 12 patients have been treated using a helical tomotherapy unit. For these 12 patients both helical and serial tomotherapy plans were computed and clinically approved. Techniques and considerations of tomotherapy SBRT planning, associated image-guidance, and delivery are presented. The respective treatment plans were compared based on dosimetric parameters as well as time to develop a treatment plan and delivery times. Also the associated quality of megavoltage CT (MVCT) image-guidance inherent to the helical tomotherapy unit was assessed. Tumor volumes averaged 9.3, 9.8, and 58.7 cm3 for liver, lung, and spinal targets. Helical and serial tomotherapy plans showed comparable plan quality with respect to maximum and average doses to the gross tumor and planning target volumes. Time to develop helical tomotherapy plans averaged 3.5 h while serial tomotherapy planning consistently required less than one hour. Treatment delivery was also slower using helical tomotherapy, with differences of less than 10 min between modalities. MVCT image-guidance proved satisfactory for bony and lung targets, but failed to depict liver lesions, owing to poor soft-tissue contrast. SBRT planning and delivery is clinically feasible using either tomotherapeutic modality. While treatment planning time was consistently shorter and more readily accomplished in a standardized approach using the serial tomotherapy modality, actual plan quality and treatment delivery times are grossly comparable between the modalities. MVCT volumetric image-guidance, was observed to be valuable for thoracic and spinal target volumes, whereas it proved challenging for liver targets.

Image-guidance protocol comparison: supine and prone set-up accuracy for pelvic radiation therapy.

Purpose. To investigate the impact of prone versus supine patient set-up and use of various image-guidance protocols on residual set-up error for radiation therapy of pelvic malignancies. We aim to identify an optimal frequency and protocol for image-guidance. Materials. Using daily online image-guidance mega-voltage CT data from 30 patients (829 MVCT; 299 prone set-up on belly board, 530 supine set-up), we retrospectively assessed the impact of various image-guidance protocols on residual set-up error. We compared daily image-guidance with three different No Action Level protocols (NAL), alternate day image-guidance with running mean and weekly image-guidance. Results. Of 5 IGRT protocols analyzed, the protocol with the highest imaging frequency, alternate day imaging with a running mean (50% imaging frequency), provided the best set-up error reduction. This protocol would have reduced the average length of 3D corrective vector shifts derived from daily image-guidance from 15.2 and 13.5 mm for prone and supine set-up, to 5 and 5.4 mm, respectively. A NAL protocol, averaging shifts of the first 3 fractions (NAL3), would have reduced the respective set-up variability to 6.3 (prone), and 7.5 mm (supine). An extended NAL (eNAL) protocol, averaging shifts of the first 3 fractions plus weekly imaging, would have reduced the daily positioning variability to 6 mm for both prone and supine set-ups. Daily image-guidance yielded set-up corrections >10 mm in 64.3% for prone and 70.3% for supine position. Use of the NAL3 protocol would have reduced the respective frequency to 14.4%, and 21.2% for prone, and supine positioning. In comparison, the alternate day running mean protocol would have reduced the frequency of shifts >10 mm to 5.5% (prone), and 8.3% (supine), respectively. Discussion. In this comparison, high frequency image-guidance provided the highest benefit with respect to residual set-up errors. However, both NAL and eNAL protocols provided significant set-up error reduction with lowered imaging frequency. While the mean 3D vector of corrective shifts was longer for prone set-up compared to the supine set-up, using any image-guidance protocol would have reduced shifts for prone set-up to a greater extent than for the supine set-up. This indicates a greater risk for systematic set-up errors in prone set-up, and larger random errors using a supine patient set-up.

Monte Carlo characterization of target doses in stereotactic body radiation therapy (SBRT)

To compare finite-size pencil beam/equivalent path-length (FSPB/EPL) and Monte Carlo (MC) SBRT dose computations for serial tomotherapy and to quantitatively assess dose differences between the dose calculation methods. Based on 72 SBRT plans for pulmonary targets, FSPB/EPL, considering the inhomogeneous lung environment, and MC calculations were performed to establish differences between FSPB/EPL predicted dose and MC derived doses. Compared with MC, FSPB/EPL consistently overestimated minimum doses to the clinical target volume and planning target volumes by an average of 18.1±7.15% (range 4 to 33.4%), and 21.9±10.4% (range 1.2 to 45.5%), respectively. The respective mean target dose differences were 15.5±7.4% (2.8–36.4%) and 19.2±7.6% (3.6–40.1%). Deviations from MC doses were lesion size and location dependent, with smaller lesions completely embedded into lung parenchyma being most susceptible. Larger lesion in contact with mediastinum and chest wall showed lesser differences. In comparison with MC dose calculation, FSPB/EPL overestimates doses delivered to pulmonary SBRT targets. The observed dose differences may have impact on local tumor control rates, and may deserve consideration when using fast, but less accurate dose calculation methods.

Delivery of four‐dimensional radiotherapy with TrackBeam for moving target using a dual‐layer MLC: dynamic phantoms study

Respiratory motion has been considered a clinical challenge for lung tumor treatments due to target motion. In this study, we aimed to perform an experimental evaluation based on dynamic phantoms using MLC‐based beam tracking. TrackBeam, a prototype real‐time beam tracking system, has been assembled and evaluated in our clinic. TrackBeam includes an orthogonal dual‐layer micro multileaf collimator (DmMLC), an on‐board mega‐voltage (MV) portal imaging device, and an image processing workstation. With a fiducial marker implanted in a moving target, the onboard imaging device can capture the motion. The TrackBeam workstation processes the online MV fluence and detects and predicts tumor motion. The DmMLC system then dynamically repositions each leaf to form new beam apertures based on the movement of the fiducial marker. In this study, a dynamic phantom was used for the measurements. Three delivery patterns were evaluated for dosimetric verification based on radiographic films: no‐motion lung‐tumor (NMLT), three‐dimensional conformal radiotherapy (3DCRT), and four‐dimensional tracking radiotherapy (4DTRT). The displacement between the DmMLC dynamic beam isocenter and the fiducial marker was in the range of 0.5 mm to 1.5 mm. With radiographic film analysis, the planar dose histogram difference between 3DCRT and NLMT was 48.6% and 38.0% with dose difference tolerances of 10% and 20%, respectively. The planar dose histogram difference between 4DTRT and NLMT was 15.2% and 4.0%, respectively. Based on dose volume histogram analysis, 4DTRT reduces the mean dose for the surrounding tissue from 35.4 Gy to 19.5 Gy, reduces the relative volume of the total lung from 28% to 18% at V20, and reduces the amount of dose from 35.2 Gy to 15.0 Gy at D20. The experimental results show that MLC‐based real‐time beam tracking delivery provides a potential solution to respiratory motion control. Beam tracking delivers a highly conformal dose to a moving target, while sparing surrounding normal tissue. PACS number: 87.55.de, 87.55.ne, 87.56.nk

Measurement and comparison of skin dose for prostate and head-and-neck patients treated on various IMRT delivery systems

Treatment planning systems inaccurately quantify dose deposited to the skin in the course of radiotherapy owing to their inability to properly account for all the surface dose contributing factors. In this work, we describe a technique for accurately measuring skin dose using ultra-thin thermoluminescent dosimeters and EBT gafchromic films. We investigated the variation in average skin dose for prostate and head-and-neck patients undergoing radiotherapy on three IMRT systems including serial/helical tomotherapy, and IMRT-step and shoot system. Helical tomotherapy was observed to deposit the highest average skin dose followed by serial tomotherapy delivery system.

A Prediction Study on Radiation-induced Second Malignancies for IMRT Treatment Delivery

Low-level peripheral organ dose and its effect on second malignancies for patients undergoing radiation therapy have been reported in the literature. However, a comprehensive database outlining the treatment modalities, the tumor location, and a quantification of the overall relative risk of second malignancies is rather limited. In this work, we quantify the relative risks or percent likelihood of second malignancies for patients undergoing IMRT and conventional radiotherapy for four different tumor sites: breast, head and neck, lung, and prostate. We utilize Monte Carlo methods based on actual patient plans to compute the whole body effective dose equivalent for each plan and then deduce the percent likelihood of the occurrence of second malignancy. Based on an evaluation of over 30 actual patient plans and Monte Carlo simulations using 6, 10, and 18MV photon beam energies, we observed that the IMRT patients treated for head and neck cancer showed a 40% increase in risk for developing a second malignancy compared to those treated with conventional radiotherapy. The increase in risk for prostrate patients was 30% while the IMRT lung patients gave the highest relative risk almost tripling that observed in their conventionally treated counterparts. There was negligible difference in risk between breast patients undergoing IMRT treatment versus conventional therapy. The overall relative risk of radiation induced malignancy observed was below 6% in all treatment plans considered.

The effect of a limited number of projections and reconstruction algorithms on the image quality of megavoltage digital tomosynthesis.

In order to investigate the effect of the number of projections on digital tomosynthesis image quality, images were acquired over a 40 degree arc and sampled into sets of 2 to 41 projections used as input to three different reconstruction algorithms: the shift‐and‐add, the Feldkamp‐Davis‐Kress filtered back projection algorithms, and the simultaneous algebraic reconstruction technique. The variation of several image characteristics, such as in‐plane resolution, contrast to noise ratio, artifact spread, volumetric accuracy, and dose, are investigated based on the reconstruction algorithms used and also the number of projections used as source data. The results suggest that only 11 projections are required since the various parameters checked do not improve much past that number. As a reconstruction algorithm, SART did best but took much longer to reconstruct images. Thus, if reconstruction time is a determining factor, filtered back‐projection looks like a better compromise. PACS number: 87.57.C‐, 87.57.nf, 87.57.Q‐, 87.59.‐e

Dosimetric characteristics of dual-layer multileaf collimation for small-field and intensity-modulated radiation therapy applications

The purpose of the present work was to measure the performance characteristics in the penumbra region and on the leaf‐end of an innovative dual‐layer micro multileaf collimator (DmMLC). The DmMLC consists of two orthogonal (upper and lower) layers of leaves; a standard MLC consists of one layer. The DmMLC provides unique performance characteristics in smoothing dose undulation, reducing leaf‐end transmission, and reducing MLC field dependence of the leaf stepping angle. Two standard MLCs (80‐leaf and 120‐leaf versions: Varian Medical Systems, Palo Alto, CA), a DmMLC (AccuKnife: Initia Medical Technology, Canton, MA), and a Cerrobend (Cerro Metal Products, Bellefonte, PA) block were used in performance studies involving a triangular field, a cross leaf‐end field, and a circular field. Measurements were made with 6‐MV X‐rays and extended dose range film at a depth of 5 cm in Solid Water (Gammex rmi, Middleton, WI) at a source–axis distance of 100 cm. The field penumbra width measured between the 20% and 80% isodose lines through the MLC‐80, MLC‐120, DmMLC, and Cerrobend block were 9.0, 5.0, 3.0, and 2.0 mm respectively. The dose undulation amplitude of the 50% isodose line was measured as 5.5, 2.0, and 0.5 mm for the MLC‐80, MLC‐120, and DmMLC respectively. The planar dose difference between the MLC‐80, MLC‐120, and DmMLC against Cerrobend block was measured as ranging at ±52.5%,±35.0%, and ±20.0% respectively. The leaf‐end transmission was measured at 22.4% in maximum and 15.4% in average when closing a single layer of the DmMLC, and at 2.4% in maximum and 2.1% in average when closing both layers. The MLC dependence of the leaf stepping angle with the DmMLC ranged from 45 degrees to 90 degrees. The standard MLC leaf stepping angle ranged from 0 degrees to 90 degrees. In conclusion, the dose undulation, leaf‐end transmission, and MLC field dependence of the leaf stepping angle with the DmMLC were remarkably reduced as compared with those of the standard MLCs. And as compared with Cerrobend block, the DmMLC provided very comparable performance in field‐edge smoothing and in the shaping of complex fields. PACS numbers: 87.56.Jk, 87.56.Nk, 87.56.Nj, 87.57.Nt