N Yue

Synchrony – Cyberknife Respiratory Compensation Technology

Studies of organs in the thorax and abdomen have shown that these organs can move as much as 40 mm due to respiratory motion. Without compensation for this motion during the course of external beam radiation therapy, the dose coverage to target may be compromised. On the other hand, if compensation of this motion is by expansion of the margin around the target, a significant volume of normal tissue may be unnecessarily irradiated. In hypofractionated regimens, the issue of respiratory compensation becomes an important factor and is critical in single-fraction extracranial radiosurgery applications. CyberKnife is an image-guided radiosurgery system that consists of a 6-MV LINAC mounted to a robotic arm coupled through a control loop to a digital diagnostic x-ray imaging system. The robotic arm can point the beam anywhere in space with 6 degrees of freedom, without being constrained to a conventional isocenter. The CyberKnife has been recently upgraded with a real-time respiratory tracking and compensation system called Synchrony. Using external markers in conjunction with diagnostic x-ray images, Synchrony helps guide the robotic arm to move the radiation beam in real time such that the beam always remains aligned with the target. With the aid of Synchrony, the tumor motion can be tracked in three-dimensional space, and the motion-induced dosimetric change to target can be minimized with a limited margin. The working principles, advantages, limitations, and our clinical experience with this new technology will be discussed.

The intrafraction motion induced dosimetric impacts in breast 3D radiation treatment: A 4DCT based study

The question remains regarding the dosimetric impact of intrafraction motion in 3D breast treatment. This study was conducted to investigate this issue utilizing the 4DCT scan. The 4D and helical CT scan sets were acquired for 12 breast cancer patients. For each of these patients, based on the helical CT scan, a conventional 3D conformal plan was generated. The breast treatment was then simulated based on the 4DCT scan. In each phase of the 4DCT scan, dose distribution was generated with the same beam parameters as the conventional plan. A software package was developed to compute the cumulative dose distribution from all the phases. Since the intrafraction organ motion is reflected by the 4DCT images, the cumulative dose computed based on the 4DCT images should be closer to what the patient received during treatment. Various dosimetric parameters were obtained from the plan and 4D cumulative dose distribution for the target volume and heart, and were compared to deduce the motion-induced impacts. The studies were performed for both whole breast and partial breast treatment. In the whole breast treatment, the average intrafraction motion induced changes in D95, D90, V100, V95, and V90 of the target volume were -5.4%, -3.1%, -13.4%, -5.1%, and -3.2%, respectively, with the largest values at -26.2%, -14.1%, -91.0%, -15.1%, and -9.0%, respectively. Motion had little impact on the Dmax of the target volume, but its impact on the Dmin of the target volume was significant. For left breast treatment, the motion-induced Dmax change to the heart could be negative or positive, with the largest increase at about 6 Gy. In partial breast treatment, the only non-insignificant impact was in the Dmin of the CTV (ranging from -15.2% to 11.7%). The results showed that the intrafraction motion may compromise target dose coverage in breast treatments and the degree of that compromise was correlated with motion magnitude. However, the dosimetric impact of the motion on the heart dose may be limited.

FOUR-DIMENSIONAL COMPUTED TOMOGRAPHY-BASED INTERFRACTIONAL REPRODUCIBILITY STUDY OF LUNG TUMOR INTRAFRACTIONAL MOTION

PURPOSEnTo evaluate the interfractional reproducibility of respiration-induced lung tumors motion, defined by their centroids and the intrafractional target motion range.nnnMETHODS AND MATERIALSnTwentythree pairs of four-dimensional/computed tomography scans were acquired for 22 patients. Gross tumor volumes were contoured, Clinical target volumes (CTVs) were generated. Geometric data for CTVs and lung volumes were extracted. The motion tracks of CTV centroids, and CTV edges along the cranio-caudal, anterior-posterior, and lateral directions were evaluated. The Pearson correlation coefficient for motion tracks along the cranio-caudal direction was determined for the entire respiratory cycle and for five phases about the end of expiration.nnnRESULTSnThe largest motion extent was along the cranio-caudal direction. The intrafractional motion extent for five CTVs was <0.5 cm, the largest motion range was 3.59 cm. Three CTVs with respiration-induced displacement >0.5 cm did not exhibit the similarity of motion, and for 16 CTVs with motion >0.5 cm the correlation coefficient was >0.8. The lung volumes in corresponding phases for cases that demonstrated CTVs motion similarity were reproducible. No correlation between tumor size and mobility was found.nnnCONCLUSIONnTarget motion reproducibility seems to be present in 87% of cases in our dataset. Three cases with dissimilar motion indicate that it is advisable to verify target motion during treatment. The adaptive adjustment to compensate the possible interfractional shifts in a target position should be incorporated as a routine policy for lung cancer radiotherapy.

The effect of respiratory cycle and radiation beam-on timing on the dose distribution of free-breathing breast treatment using dynamic IMRT.

In breast cancer treatment, intensity-modulated radiation therapy (IMRT) can be utilized to deliver more homogeneous dose to target tissues to minimize the cosmetic impact. We have investigated the effect of the respiratory cycle and radiation beam-on timing on the dose distribution in free-breathing dynamic breast IMRT treatment. Six patients with early stage cancer of the left breast were included in this study. A helical computed tomography (CT) scan was acquired for treatment planning. A four-dimensional computed tomography (4D CT) scan was obtained right after the helical CT scan with little or no setup uncertainty to simulate patient respiratory motion. After optimizing based on the helical CT scan, the sliding-window dynamic multileaf collimator (DMLC) leaf sequence was segmented into multiple sections that corresponded to various respiratory phases per respiratory cycle and radiation beam-on timing. The segmented DMLC leaf sections were grouped according to respiratory phases and superimposed over the radiation fields of corresponding 4D CT image set. Dose calculation was then performed for each phase of the 4D CT scan. The total dose distribution was computed by accumulating the contribution of dose from each phase to every voxel in the region of interest. This was tracked by a deformable registration program throughout all of the respiratory phases of the 4D CT scan. A dose heterogeneity index, defined as the ratio between (D20-D80) and the prescription dose, was introduced to numerically illustrate the impact of respiratory motion on the dose distribution of treatment volume. A respiratory cycle range of 4-8 s and randomly distributed beam-on timing were assigned to simulate the patient respiratory motion during the free-breathing treatment. The results showed that the respiratory cycle period and radiation beam-on timing presented limited impact on the target dose coverage and slightly increased the target dose heterogeneity. This motion impact tended to increase the variation of target dose coverage and heterogeneity between treatment fractions with different radiation beam-on timing. The target dose coverage and heterogeneity were more susceptible to the radiation beam-on timing for patients with long respiratory cycle (longer than 6 s) and large breast motion amplitudes (larger than 0.7 cm). The same results could be found for respiratory cycle up to 8 s and respiratory motion amplitude up to 1 cm. The heart dose distribution did not change significantly regardless of respiratory cycle and radiation beam-on timing.

A dose verification method using a monitor unit matrix for dynamic IMRT on Varian linear accelerators

Dosimetry verification is an important step during intensity modulated radiotherapy treatment (IMRT). The verification is usually conducted with measurements and independent dose calculations. However, currently available independent dose calculation methods were developed for step-and-shoot beam delivery methods, and their uses for dynamic multi-leaf collimator (MLC) delivery methods are not efficient. In this study, a dose calculation method was developed to perform independent dose verifications for a dynamic MLC-based IMRT technique for Varian linear accelerators. This method extracts the machine delivery parameters from the dynamic MLC (DMLC) files generated by the IMRT treatment planning system. Based on the parameters a monitor unit (MU) matrix was separately calculated as two terms: direct exposure from the open MLC field and leakage contributions, where the leaf-end leakage contribution becomes more important in higher dose gradient regions. The MU matrix was used to compute the primary dose and the scattered dose with a modified Clarkson technique. The doses computed using the method were compared with both measurement and treatment planning for 14 and 25 plans respectively. An average of less than 2% agreement was observed and the standard deviation was about 1.9%.

Third party brachytherapy seed calibrations and physicist responsibilities

To the Editor, In the last decade, the number of low-energy photonemitting brachytherapy source manufacturers has dramatically grown, and there are now about 15 manufacturers for I and Pd encapsulated sources for permanent and temporary brachytherapy. More recently, several third party calibration services, some based in commercial radiopharmacies, have begun marketing “independent assays” of brachytherapy source strength. For a fee, these services perform seed strength assay for an order prior to shipping it to the end user. While such services help reduce the physics workload required in source preparation for brachytherapy implants, they also raise certain medical physics, patient safety, and legal issues regarding American Association of Physicists in Medicine AAPM recommendations that have been published in Medical Physics. In 1997, AAPM TG-56 guidance states, “Every institution practicing brachytherapy shall have a system for measuring source strength with secondary traceability for all source types used in its practice.” The report further states, “The institution should compare the manufacturer’s stated value with the institution’s standard.” In 1999, the issue of whether source strength can be verified by entities other than the final user’s institution was addressed again in Medical Physics when AAPM TG-64 restated and condensed TG-56 recommendations as, “In whatever form the seeds are procured, the manufacturer’s assay must be independently confirmed.” In this letter, we intend to update the Medical Physics readership regarding the current deliberations and actions that are underway in addressing these urgent issues raised by the use of third party brachytherapy seed calibrations. This letter has been prepared by members of the AAPM Brachytherapy Subcommittee of the Therapy Physics Committee and was approved for publication by the AAPM Therapy Physics Committee. In our opinion, use of third party calibration services that provide independent source strength verification would appear to provide nominal adherence to TG-64, but not necessarily to TG-56. Additionally, use of such calibrations to replace TG-56 compliant end-user measurements raises questions and concerns. It is the AAPM’s position that a qualified medical physicist is responsible for the dosimetric accuracy of brachytherapy treatment plans, including source strengths. This position is also supported by state regulatory bodies and professional organizations such as the American College of Radiology ACR , American Brachytherapy Society ABS , American College of Medical

External beam radiotherapy boosts to reduce the impact caused by edema in prostate permanent seed implants

In prostate permanent seed implants, it has been shown that edema caused by the surgical procedure decreases dose coverage and hence may reduce treatment efficacy. This reduction in treatment efficacy has been characterized by an increase in tumour cell survival, and biomathematical models have been developed to calculate the tumour cell survival increases in seed implanted prostates of different edema magnitudes and durations. External beam boosts can be utilized to neutralize the negative impact of edema so that originally desired treatment efficacy can be achieved. In this study, a linear quadratic model is used to determine fractionation sizes of the external beam boosts for both (125)I and (103)Pd seed implants. Calculations were performed for prostates of different edema magnitudes and durations, and for tumour cells of different repair rates and repopulation rates.

MO-H-19A-03: Patient Specific Bolus with 3D Printing Technology for Electron Radiotherapy

PURPOSEnBolus is widely used in electron radiotherapy to achieve desired dose distribution. 3D printing technologies provide clinicians with easy access to fabricate patient specific bolus accommodating patient body surface irregularities and tissue inhomogeneity. This study presents the design and the clinical workflow of 3D printed bolus for patient electron therapy in our clinic.nnnMETHODSnPatient simulation CT images free of bolus were exported from treatment planning system (TPS) to an in-house developed software package. Bolus with known material properties was designed in the software package and then exported back to the TPS as a structure. Dose calculation was carried out to examine the coverage of the target. After satisfying dose distribution was achieved, the bolus structure was transferred in Standard Tessellation Language (STL) file format for the 3D printer to generate the machine codes for printing. Upon receiving printed bolus, a quick quality assurance was performed with patient resimulated with bolus in place to verify the bolus dosimetric property before treatment started.nnnRESULTSnA patient specific bolus for electron radiotherapy was designed and fabricated in Form 1 3D printer with methacrylate photopolymer resin. Satisfying dose distribution was achieved in patient with bolus setup. Treatment was successfully finished for one patient with the 3D printed bolus.nnnCONCLUSIONnThe electron bolus fabrication with 3D printing technology was successfully implemented in clinic practice.

SU-E-J-263: Dosimetric Analysis On Breast Brachytherapy Based On Deformable Image Registration

PURPOSEnTo quantitatively compare and evaluate the dosimetry difference between breast brachytherapy protocols with different fractionation using deformable image registration.nnnMETHODSnThe accumulative dose distribution for multiple breast brachytherapy patients using four different applicators: Contura, Mammosite, Savi, and interstitial catheters, under two treatment protocols: 340cGy by 10 fractions in 5 days and 825cGy by 3 fractions in 2days has been reconstructed using a two stage deformable image registration approach. For all patients, daily CT was acquired with the same slice thickness (2.5mm). In the first stage, the daily CT images were rigidly registered to the initial planning CT using the registration module in Eclipse (Varian) to align the applicators. In the second stage, the tissues surrounding the applicator in the rigidly registered daily CT image were non-rigidly registered to the initial CT using a combination of image force and the local constraint that enforce zero normal motion on the surface of the applicator, using a software developed in house. We calculated the dose distribution in the daily CTs and deformed them using the final registration to convert into the image domain of the initial planning CT. The accumulative dose distributions were evaluated by dosimetry parameters including D90, V150 and V200, as well as DVH.nnnRESULTSnDose reconstruction results showed that the two day treatment has a significant dosimetry improvement over the five day protocols. An average daily drop of D90 at 1.3% of the prescription dose has been observed on multiple brachytherapy patients. There is no significant difference on V150 and V200 between those two protocols.nnnCONCLUSIONnBrachytherapy with higher fractional dose and less fractions has an improved performance on being conformal to the dose distribution in the initial plan. Elongated brachytherapy treatments need to consider the dose uncertainty caused by the temporal changes of the soft tissue.

SU-E-T-497: Semi-Automated in Vivo Radiochromic Film Dosimetry Using a Novel Image Processing Algorithm

PURPOSEnTo validate an automated image processing algorithm designed to detect the center of radiochromic film used for in vivo film dosimetry against the current gold standard of manual selection.nnnMETHODSnAn image processing algorithm was developed to automatically select the region of interest (ROI) in *.tiff images that contain multiple pieces of radiochromic film (0.5×1.3cm2 ). After a user has linked a calibration file to the processing algorithm and selected a *.tiff file for processing, an ROI is automatically detected for all films by a combination of thresholding and erosion, which removes edges and any additional markings for orientation. Calibration is applied to the mean pixel values from the ROIs and a *.tiff image is output displaying the original image with an overlay of the ROIs and the measured doses. Validation of the algorithm was determined by comparing in vivo dose determined using the current gold standard (manually drawn ROIs) versus automated ROIs for n=420 scanned films. Bland-Altman analysis, paired t-test, and linear regression were performed to demonstrate agreement between the processes.nnnRESULTSnThe measured doses ranged from 0.2-886.6cGy. Bland-Altman analysis of the two techniques (automatic minus manual) revealed a bias of -0.28cGy and a 95% confidence interval of (5.5cGy,-6.1cGy). These values demonstrate excellent agreement between the two techniques. Paired t-test results showed no statistical differences between the two techniques, p=0.98. Linear regression with a forced zero intercept demonstrated that Automatic=0.997*Manual, with a Pearson correlation coefficient of 0.999. The minimal differences between the two techniques may be explained by the fact that the hand drawn ROIs were not identical to the automatically selected ones. The average processing time was 6.7seconds in Matlab on an IntelCore2Duo processor.nnnCONCLUSIONnAn automated image processing algorithm has been developed and validated, which will help minimize user interaction and processing time of radiochromic film used for in vivo dosimetry.