P Taylor

Pencil Beam Algorithms Are Unsuitable for Proton Dose Calculations in Lung.

PURPOSE To compare analytic and Monte Carlo-based algorithms for proton dose calculations in the lung, benchmarked against anthropomorphic lung phantom measurements. METHODS AND MATERIALS A heterogeneous anthropomorphic moving lung phantom has been irradiated at numerous proton therapy centers. At 5 centers the treatment plan could be calculated with both an analytic and Monte Carlo algorithm. The doses calculated in the treatment plans were compared with the doses delivered to the phantoms, which were measured using thermoluminescent dosimeters and film. Point doses were compared, as were planar doses using a gamma analysis. RESULTS The analytic algorithms overestimated the dose to the center of the target by an average of 7.2%, whereas the Monte Carlo algorithms were within 1.6% of the physical measurements on average. In some regions of the target volume, the analytic algorithm calculations differed from the measurement by up to 31% in the internal gross target volume (iGTV) (46% in the planning target volume), over-predicting the dose. All comparisons showed a region of at least 15% dose discrepancy within the iGTV between the analytic calculation and the measured dose. The Monte Carlo algorithm recalculations showed dramatically improved agreement with the measured doses, showing mean agreement within 4% for all cases and a maximum difference of 12% within the iGTV. CONCLUSIONS Analytic algorithms often do a poor job predicting proton dose in lung tumors, over-predicting the dose to the target by up to 46%, and should not be used unless extensive validation counters the consistent results of the present study. Monte Carlo algorithms showed dramatically improved agreement with physical measurements and should be implemented to better reflect actual delivered dose distributions.

Technical Report: Reference photon dosimetry data for Varian accelerators based on IROC‐Houston site visit data

PURPOSE Accurate data regarding linear accelerator (Linac) radiation characteristics are important for treatment planning system modeling as well as regular quality assurance of the machine. The Imaging and Radiation Oncology Core-Houston (IROC-H) has measured the dosimetric characteristics of numerous machines through their on-site dosimetry review protocols. Photon data are presented and can be used as a secondary check of acquired values, as a means to verify commissioning a new machine, or in preparation for an IROC-H site visit. METHODS Photon data from IROC-H on-site reviews from 2000 to 2014 were compiled and analyzed. Specifically, data from approximately 500 Varian machines were analyzed. Each dataset consisted of point measurements of several dosimetric parameters at various locations in a water phantom to assess the percentage depth dose, jaw output factors, multileaf collimator small field output factors, off-axis factors, and wedge factors. The data were analyzed by energy and parameter, with similarly performing machine models being assimilated into classes. Common statistical metrics are presented for each machine class. Measurement data were compared against other reference data where applicable. RESULTS Distributions of the parameter data were shown to be robust and derive from a students t distribution. Based on statistical and clinical criteria, all machine models were able to be classified into two or three classes for each energy, except for 6 MV for which there were eight classes. Quantitative analysis of the measurements for 6, 10, 15, and 18 MV photon beams is presented for each parameter; supplementary material has also been made available which contains further statistical information. CONCLUSIONS IROC-H has collected numerous data on Varian Linacs and the results of photon measurements from the past 15 years are presented. The data can be used as a comparison check of a physicists acquired values. Acquired values that are well outside the expected distribution should be verified by the physicist to identify whether the measurements are valid. Comparison of values to this reference data provides a redundant check to help prevent gross dosimetric treatment errors.

Radiation Therapy Deficiencies Identified During On-Site Dosimetry Visits by the Imaging and Radiation Oncology Core Houston Quality Assurance Center

Purpose: To review the dosimetric, mechanical, and program m tic deficiencies most frequently observed during on-site visits of radiotherapy faci lities by the Imaging and adiation Oncology Core Houston office (IROC Houston). Methods: IROC Houston’s findings between 2000 and 2014, in cluding 409 institutions and 1020 linacs, were compiled. IROC Houston’s on-site evalu ation includes verification of absolute calibration (tolerance of ±3%), relative dosimetric review (tolerances of ±2% between TPS calculation and measurement), mechanical evaluation (including MLC and kV-MV evaluation against TG-142 tolerances), and general programmati c rev ew (including institutional QA program versus TG-40 and TG-142). Results: An average of 3.1 deficiencies was identified at each institution visited, a number that has decreased slightly with time. The most common error s are tabulated, and include TG-40/TG-142 compliance (82% of institutions were deficient), sm all field size output factors (59% of institutions had errors ≥3%), and wedge factors (33% of institutions had err ors ≥3%). Dosimetric errors of ≥10%, including in beam calibration, were seen at ma ny institutions. Conclusions: There is substantial room for improvement of both dosimetric and programmatic issues in radiotherapy, which should be a high prio rity for the medical physics community. Particularly relevant was suboptimal beam modeling in the treatment planning system and a corresponding failure to detect these errors by not including TPS data in the linac QA process. M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT 2PURPOSE To review the dosimetric, mechanical, and programmatic deficiencies most frequently observed during on-site visits of radiation therapy facilities by the Imaging and Radiation Oncology Core Quality Assurance Center in Houston (IROC Houston). METHODS AND MATERIALS The findings of IROC Houston between 2000 and 2014, including 409 institutions and 1020 linear accelerators (linacs), were compiled. On-site evaluations by IROC Houston include verification of absolute calibration (tolerance of ±3%), relative dosimetric review (tolerances of ±2% between treatment planning system [TPS] calculation and measurement), mechanical evaluation (including multileaf collimator and kilovoltage-megavoltage isocenter evaluation against Task Group [TG]-142 tolerances), and general programmatic review (including institutional quality assurance program vs TG-40 and TG-142). RESULTS An average of 3.1 deficiencies was identified at each institution visited, a number that has decreased slightly with time. The most common errors are tabulated and include TG-40/TG-142 compliance (82% of institutions were deficient), small field size output factors (59% of institutions had errors ≥3%), and wedge factors (33% of institutions had errors ≥3%). Dosimetric errors of ≥10%, including in beam calibration, were seen at many institutions. CONCLUSIONS There is substantial room for improvement of both dosimetric and programmatic issues in radiation therapy, which should be a high priority for the medical physics community. Particularly relevant was suboptimal beam modeling in the TPS and a corresponding failure to detect these errors by not including TPS data in the linac quality assurance process.

Examining credentialing criteria and poor performance indicators for IROC Houston's anthropomorphic head and neck phantom

PURPOSE To analyze the most recent results of the Imaging and Radiation Oncology Core Houston Quality Assurance Centers (IROC-H) anthropomorphic head and neck (H&N) phantom to determine the nature of failing irradiations and the feasibility of altering credentialing criteria. METHODS IROC-Hs H&N phantom, used for intensity-modulated radiation therapy credentialing for National Cancer Institute-sponsored clinical trials, requires that an institutions treatment plan agrees within ±7% of measured thermoluminescent dosimeter (TLD) doses; it also requires that ≥85% of pixels pass ±4 mm distance to agreement (7%/4 mm gamma analysis for film). The authors re-evaluated 156 phantom irradiations (November 1, 2014-October 31, 2015) according to the following tighter criteria: (1) 5% TLD and 5%/4 mm, (2) 5% TLD and 5%/3 mm, (3) 4% TLD and 4%/4 mm, and (4) 3% TLD and 3%/3 mm. Failure rates were evaluated with respect to individual film and TLD performance by location in the phantom. Overall poor phantom results were characterized qualitatively as systematic errors (correct shape and position but wrong magnitude of dose), setup errors/positional shifts, global but nonsystematic errors, and errors affecting only a local region. RESULTS The pass rate for these phantoms using current criteria was 90%. Substituting criteria 1-4 reduced the overall pass rate to 77%, 70%, 63%, and 37%, respectively. Statistical analyses indicated that the probability of noise-induced TLD failure, even at the 5% criterion, was <0.5%. Phantom failures were generally identified by TLD (≥66% failed TLD, whereas ≥55% failed film), with most failures occurring in the primary planning target volume (≥77% of cases). Results failing current criteria or criteria 1 were primarily diagnosed as systematic >58% of the time (11/16 and 21/36 cases, respectively), with a greater extent due to underdosing. Setup/positioning errors were seen in 11%-13% of all failing cases (2/16 and 4/36 cases, respectively). Local errors (8/36 cases) could only be demonstrated at criteria 1. Only three cases of global errors were identified in these analyses. For current criteria and criteria 1, irradiations that failed from film only were overwhelmingly associated with phantom shifts/setup errors (≥80% of cases). CONCLUSIONS This study highlighted that the majority of phantom failures are the result of systematic dosimetric discrepancies between the treatment planning system and the delivered dose. Further work is necessary to diagnose and resolve such dosimetric inaccuracy. In addition, the authors found that 5% TLD and 5%/4 mm gamma criteria may be both practically and theoretically achievable as an alternative to current criteria.

SU‐F‐T‐181: Proton Therapy Tissue‐Equivalence of 3D Printed Materials

PURPOSE This work investigated the proton tissue-equivalence of various 3D printed materials. METHODS Three 3D printers were used to create 5 cm cubic phantoms made of different plastics with varying percentages of infill. White resin, polylactic acid (PLA), and NinjaFlex plastics were used. The infills ranged from 15% to 100%. Each phantom was scanned with a CT scanner to obtain the HU value. The relative linear stopping power (RLSP) was then determined using a multi-layer ion chamber in a 200 MeV proton beam. The RLSP was measured both parallel and perpendicular to the print direction for each material. RESULTS The HU values of the materials ranged from lung-equivalent (-820 HU σ160) when using a low infill, to soft-tissue-equivalent 159 (σ12). The RLSP of the materials depended on the orientation of the beam relative to the print direction. When the proton beam was parallel to the print direction, the RLSP was generally higher than the RLSP in the perpendicular orientation, by up to 45%. This difference was smaller (less than 6%) for the materials with 100% infill. For low infill cubes irradiated parallel to the print direction, the SOBP curve showed extreme degradation of the beam in the distal region. The materials with 15-25% infill had wide-ranging agreement with a clinical HU-RLSP conversion curve, with some measurements falling within 1% of the curve and others deviating up to 45%. The materials with 100% infill all fell within 7% of the curve. CONCLUSION While some materials tested fall within 1% of a clinical HU-RLSP curve, caution should be taken when using 3D printed materials with proton therapy, as the orientation of the beam relative to the print direction can result in a large change in RLSP. Further investigation is needed to measure how the infill pattern affects the material RLSP. This work was supported by PHS grant CA180803.

SU-F-T-485: Independent Remote Audits for TG51 NonCompliant Photon Beams Performed by the IROC Houston QA Center

PURPOSE IROC_H conducts external audits for output check verification of photon and electron beams. Many of these beams can meet the geometric requirements of the TG 51 calibration protocol. For those photon beams that are non TG 51 compliant like Elekta GammaKnife, Accuray CyberKnife and TomoTherapy, IROC_H has specific audit tools to monitor the reference calibration. METHODS IROC_H used its TLD and OSLD remote monitoring systems to verify the output of machines with TG 51 non compliant beams. Acrylic OSLD miniphantoms are used for the CyberKnife. Special TLD phantoms are used for TomoTherapy and GammaKnife machines to accommodate the specific geometry of each machine. These remote audit tools are sent to institutions to be irradiated and returned to IROC_H for analysis. RESULTS The average IROC_H/institution ratios for 480 GammaKnife, 660 CyberKnife and 907 rotational TomoTherapy beams are 1.000±0.021, 1.008±0.019, 0.974±0.023, respectively. In the particular case of TomoTherapy, the overall ratio is 0.977±0.022 for HD units. The standard deviations of all results are consistent with values determined for TG 51 compliant photon beams. These ratios have shown some changes compared to values presented in 2008. The GammaKnife results were corrected by an experimentally determined scatter factor of 1.025 in 2013. The TomoTherapy helical beam results are now from a rotational beam whereas in 2008 the results were from a static beam. The decision to change modality was based on recommendations from the users. CONCLUSION External audits of beam outputs is a valuable tool to confirm the calibrations of photon beams regardless of whether the machine is TG 51 or TG 51 non compliant. The difference found for TomoTherapy units is under investigation. This investigation was supported by IROC grant CA180803 awarded by the NCI.

Remote beam output audits: A global assessment of results out of tolerance

Background and purpose Remote beam output audits, which independently measure an institution’s machine calibration, are a common component of independent radiotherapy peer review. This work reviews the results and trends of these audit results across several organisations and geographical regions. Materials and methods Beam output audit results from the Australian Clinical Dosimetry Services, International Atomic Energy Agency, Imaging and Radiation Oncology Core, and Radiation Dosimetry Services were evaluated from 2010 to the present. The rate of audit results outside a ±5% tolerance was evaluated for photon and electron beams as a function of the year of irradiation and nominal beam energy. Additionally, examples of confirmed calibration errors were examined to provide guidance to clinical physicists and auditing bodies. Results Of the 210,167 audit results, 1323 (0.63%) were outside of tolerance. There was a clear trend of improved audit performance for more recent dates, and while all photon energies generally showed uniform rates of results out of tolerance, low (6 MeV) and high (≥18 MeV) energy electron beams showed significantly elevated rates. Twenty nine confirmed calibration errors were explored and attributed to a range of issues, such as equipment failures, errors in setup, and errors in performing the clinical reference calibration. Forty-two percent of these confirmed errors were detected during ongoing periodic monitoring, and not at the time of the first audit of the machine. Conclusions Remote beam output audits have identified, and continue to identify, numerous and often substantial beam calibration errors.

Reference dosimetry data and modeling challenges for Elekta accelerators based on IROC‐Houston site visit data

PURPOSE Reference dosimetry data can provide an independent second check of acquired values when commissioning or validating a treatment planning system (TPS). The Imaging and Radiation Oncology Core at Houston (IROC-Houston) has measured numerous linear accelerators throughout its existence. The results of those measurements are given here, comparing accelerators and the agreement of measurement versus institutional TPS calculations. METHODS Data from IROC-Houston on-site reviews from 2000 through 2014 were analyzed for all Elekta accelerators, approximately 50. For each, consistent point dose measurements were conducted for several basic parameters in a water phantom, including percentage depth dose, output factors, small-field output factors, off-axis factors, and wedge factors. The results were compared by accelerator type independently for 6, 10, 15, and 18 MV. Distributions of the measurements for each parameter are given, providing the mean and standard deviation. Each accelerators measurements were also compared to its corresponding TPS calculation from the institution to determine the level of agreement, as well as determining which dosimetric parameters were most often in error. RESULTS Accelerators were grouped by head type and reference dosimetric values were compiled. No class of linac had better overall agreement with its TPS, but percentage depth dose and output factors commonly agreed well, while small-field output factors, off-axis factors, and wedge factors often disagreed substantially from their TPS calculations. CONCLUSION Reference data has been collected and analyzed for numerous Elekta linacs, which provide an independent way for a physicist to double-check their own measurements to prevent gross treatment errors. In addition, treatment planning parameters more often in error have been highlighted, providing practical caution for physicists commissioning treatment planning systems for Elekta linacs.

Clinical examination of proton pencil beam scanning on a moving anthropomorphic lung phantom

The objective of this study was to examine the use of proton pencil beam scanning for the treatment of moving lung tumors. A single-field uniform dose proton pencil beam scanning (PBS) plan was generated for the standard thorax phantom designed by the Imaging and Radiation Oncology Core (IROC) Houston QA Center. Robust optimization, including range and setup uncertainties as well as volumetric repainting, was used for the plan. Patient-specific quality assurance (QA) measurements were performed using both a water tank and a custom heterogeneous QA phantom. A custom moving phantom was used to find the optimal number of volumetric repainting. Both analytical and Monte Carlo (MC) algorithms were used for dose calculation and their accuracies were compared with actual measurements. A single ionization chamber, a 2-dimensional ionization chamber array, thermoluminescent dosimeters (TLDs), and films were used for dose measurements. The optimal number of volumetric repainting was found to be 4 times in our system. The mean dose overestimations on a moving target by analytical and MC algorithms based on a time-averaged computed tomography (CT) image of the phantom were found to be 4.8% and 2.4%, respectively. The mean gamma indexes for analytical and MC algorithms were 91% and 96%, respectively. The MC dose algorithm calculation was found to have a better agreement with measurements compared with the analytical algorithm. When treating moving lung tumors using proton PBS, the techniques of robust optimization, volumetric repainting, and MC dose calculation were found effective. Extra care needs to be taken when an analytical dose calculation algorithm is used.

A New Anthropomorphic Pediatric Spine Phantom for Proton Therapy Clinical Trial Credentialing

Purpose To design and evaluate an anthropomorphic spine phantom for use in credentialing proton therapy facilities for clinical trial participation by the Imaging and Radiation Oncology Core Houston QA Center. Materials and Methods A phantom was designed to perform an end-to-end audit of the proton spine treatment process, including simulation, dose calculation, and proton treatment delivery. Because plastics that simulate bone in proton beams are unknown, 11 potential materials were tested to identify suitable phantom materials. Once built, preliminary testing using passive scattering and spot scanning treatment plans (including a field junction) were created in-house and delivered 3 times to test reproducibility. The following measured attributes were compared with the calculated values: absolute dose agreement using thermoluminescent dosimeters, planar gamma agreement, distal range, junction match, and right and left profile alignment using radiochromic film. Finally, credentialing results from 10 institutions were also assessed. Results A suitable bone substitute was identified (Techtron HPV Bearing Grade), which had a measured relative stopping power that agreed within 1.1% of its value calculated by Eclipse. In-house passive scatter testing of the phantom demonstrated that the phantom was suitable for assessing craniospinal irradiation dose delivery. However, the in-house scanning beam results were more mixed, highlighting challenges in treatment delivery. Seven of ten institutions passed the proposed criteria for this phantom, a pass rate consistent with other Imaging and Radiation Oncology phantoms. Conclusions An anthropomorphic proton spine phantom was developed to evaluate proton therapy delivery. This phantom provides a realistic challenge for centers wishing to participate in proton clinical trials and highlights the need for caution in applying advanced treatments.